Seifu T. Tesfay

Laparoscopic skills training

BACKGROUND The purpose of this study was to quantify the learning curve of a previously validated laparoscopic skills curriculum. METHODS Second-year medical students (MS2, n = 11) and second (PGY2, n = 11) and third (PGY3, n = 6) year surgery residents were enrolled into a curriculum using five video-trainer tasks. All subjects underwent baseline testing, training (30 minutes per day for 10 days), and final testing. Scores were based on completion time. The relationship between task completion time and the number of practice repetitions was examined. Improvement (the difference in baseline and final performance) amongst groups was compared by one-way analysis of variance using the baseline score as a covariate; P <0.05 indicated significance. RESULTS Baseline scores were not significantly different. Final scores were significantly better for MS2s versus PGY3s. Adjusted-improvement was significantly larger for the MS2s compared with PGY2s and PGY3s, and for PGY2s compared with PGY3s. The mean number of repetitions corresponding to a predicted 90th percentile score was 32. CONCLUSION Inexperienced subjects benefit the most from skills training. For maximal benefit, we recommend that each task be practiced for at least 30 to 35 repetitions.

Measuring Operative Performance after Laparoscopic Skills Training: Edited Videotape versus Direct Observation

BACKGROUND AND PURPOSE Global assessment by direct observation has been validated for evaluating operative performance of surgery residents after formal skills training but is time-consuming. The purpose of this study was to compare global assessment performed from edited videotape with scores from direct observation. MATERIALS AND METHODS Junior surgery residents (N = 22) were randomized to 2 weeks of formal videotrainer skills training or a control group. Laparoscopic cholecystectomy was performed at the beginning and end of the rotation, and global assessment scores were compared for the training and control groups. Laparoscopic videotapes were edited: initial (2 minutes), cystic duct/artery (6 minutes), and fossa dissection (2 minutes). Two independent raters performed both direct observation and videotape assessments, and scores were compared for each rater and for interrater reliability using a Spearman correlation. RESULTS Correlation coefficients for videotape versus direct observation for five global assessment criteria were <0.33 for both raters (NS for all values). The correlation coefficient for interrater reliability for the overall score was 0.57 (P = 0.01) for direct observation v 0.28 (NS) for videotape. The trained group had significantly better overall performance than the control group according to the assessment by direct observation (P = 0.02) but not by videotape assessment (NS). CONCLUSIONS Direct observation demonstrated improved overall performance of junior residents after formal skills training on a videotrainer. Global assessment from an edited 10-minute videotape did not correlate with direct observation and had poor interrater reliability. Efficient and valid methods of evaluating operative performance await development.

Developing a comprehensive, proficiency-based training program for robotic surgery.

INTRODUCTION Robotically assisted surgery has become very popular for numerous surgical disciplines, yet training practices remain variable with little to no validation. The purpose of this study was to develop a comprehensive, proficiency-based robotic training program. METHODS A skill deconstruction list was generated by observation of robotic operations and interviews with experts. Available resources were used, and other components were developed as needed to develop a comprehensive, proficiency-based curriculum to teach all deconstructed skills. Preliminary construct and content validity and curriculum feasibility were evaluated. RESULTS The skill deconstruction list contained 23 items. Curricular components included an online tutorial, a half-day interactive session, and 9 inanimate exercises with objective metrics. Novice (546 ± 26) and expert (923 ± 60) inanimate composite scores were different (P < .001), supporting construct validity, and substantial pre-test to post-test improvement was noted after successful training completion. All 23 deconstructed skills were rated as highly relevant (4.9 ± 0.5; 5-point scale), and no skills were absent from the curriculum, supporting content validity. CONCLUSION These data suggest that this proficiency-based training curriculum comprehensively addresses the skills necessary to perform robotic operations with early construct and content validity and feasibility demonstrated. Further validation is encouraged.

Implementation, construct validity, and benefit of a proficiency-based knot-tying and suturing curriculum

OBJECTIVES The aim of this proficiency-based, open knot-tying and suturing study was to evaluate the feasibility of implementing this curriculum within a residency program, and to assess construct validity and educational benefit. METHODS PGY1 residents (n = 37) were enrolled in an Institutional Review Board (IRB)-approved prospective study that was conducted over a 12-week period. Trainees viewed a video tutorial during orientation and as needed; they self-practiced to proficiency for 12 standardized knot-tying, practiced suturing tasks; performed 1 repetition of each task at baseline and posttesting; and completed questionnaires. RESULTS Curriculum implementation required 376 person-hours, and material costs were

Two-year skill retention and certification exam performance after fundamentals of laparoscopic skills training and proficiency maintenance

776. All trainees achieved proficiency within allotted 12 weeks. Overall, trainees completed 141 +/- 80 repetitions over 12.7 +/- 5.3 hours in addition to performing 13.4 +/- 12.4 operations. Baseline trainee and expert performance were significantly different for all 12 tasks and composite score (732 +/- 294 vs 1488 +/- 26, p < 0.001), which supported construct validity. Baseline trainees demonstrated significant improvement at posttesting according to composite scores (732 +/- 294 vs 1503 +/- 131, p < 0.001), which validates skill acquisition. CONCLUSIONS Implementation of this proficiency-based curriculum within the constraints of a residency program is feasible. This curriculum is educationally beneficial and cost effective; our data support construct validity. Evaluation of transferability to the operating room and more widespread adoption of this curriculum are warranted.

Content and face validity of a comprehensive robotic skills training program for general surgery, urology, and gynecology

BACKGROUND The purpose of this study was to determine 2-year performance retention and certification exam pass rate after completion of a proficiency-based fundamental laparoscopic skills (FLS) curriculum and subsequent interval training. METHODS Surgery residents (postgraduate year [PGY]1-5, n = 91) were enrolled in an Institutional Review Board approved protocol. All participants initially underwent proficiency-based training on all 5 FLS tasks. Subsequently, available residents were enrolled every 6 months in an ongoing training curriculum that included retention tests on tasks 4 and 5, with mandatory retraining to proficiency if the proficiency levels were not achieved. The final retention test included the actual FLS certification examination for PGY4-5 trainees. RESULTS A 96% participation rate was achieved for all curricular components during the 2-year study period (PGY3-5, n = 33). Skill retention at retention 1-4 was 83%, 94%, 98%, and 91% for task 4 and 85%, 95%, 96%, and 100% for task 5, respectively. All PGY4-5 (n = 20) residents passed the FLS certification examination, achieving 413 +/- 28 total score on the skills portion (passing score > or =270) and demonstrating 92% retention for all 5 tasks. CONCLUSION Proficiency-based training with subsequent ongoing practice results in a very high level of skill retention after 2 years and uniformly allows trainees to pass the FLS certification examination.

Laparoscopic Roux-en-Y Gastric Bypass Using the Porcine Model

BACKGROUND The authors previously developed a comprehensive, proficiency-based robotic training curriculum that aimed to address 23 unique skills identified via task deconstruction of robotic operations. The purpose of this study was to determine the content and face validity of this curriculum. METHODS Expert robotic surgeons (n = 12) rated each deconstructed skill regarding relevance to robotic operations, were oriented to the curricular components, performed 3 to 5 repetitions on the 9 exercises, and rated each exercise. RESULTS In terms of content validity, experts rated all 23 deconstructed skills as highly relevant (4.5 on a 5-point scale). Ratings for the 9 inanimate exercises indicated moderate to thorough measurement of designated skills. For face validity, experts indicated that each exercise effectively measured relevant skills (100% agreement) and was highly effective for training and assessment (4.5 on a 5-point scale). CONCLUSIONS These data indicate that the 23 deconstructed skills accurately represent the appropriate content for robotic skills training and strongly support content and face validity for this curriculum.

Construct and face validity of the American College of Surgeons/Association of Program Directors in Surgery laparoscopic troubleshooting team training exercise

Background: The laparoscopic Roux-en-Y gastric bypass (LRYGBP) may be performed using a variety of methods. The purpose of this study was to learn how to perform the Roux-en-Y gastric bypass operation laparoscopically, using a porcine model. Materials and Methods: 11 domestic pigs (mean weight 47 kg) underwent LRYGBP. In 8 animals, a completely laparoscopic approach was attempted, while in 3 animals a hand-assist device was used. Techniques for anvil placement, pouch calibration, and limb-length measurement were evaluated. Animals were sacrificed at the end of the procedure, and operative results were recorded. Results: The hand-assist device restored tactile feedback but obscured visualization. The gastroje-junostomy leak rate was 64%, and the jejuno-jejunostomy leak rate was 73%. Anvil placement using transgastric and transoral methods was feasible. Calibrating the pouch with a Bakers tube was more accurate than using anatomical landmarks. Measuring limb-lengths using Babcock clamps was reliable with practice. Conclusion: The frailty of the porcine small intestine may limit ones ability to achieve intact anastomoses. Despite the anatomic limitations, the porcine model was well-suited for skill development and evaluation of techniques for performing the LRYGBP operation.

The southwestern center for minimally invasive surgery.

BACKGROUND Our aim was to develop an objective scoring system and evaluate construct and face validity for a laparoscopic troubleshooting team training exercise. METHODS Surgery and gynecology novices (n = 14) and experts (n = 10) participated. Assessments included the following: time-out, scenario decision making (SDM) score (based on essential treatments rendered and completion time), operating room communication assessment (investigator developed), line operations safety audits (teamwork), and National Aeronautics and Space Administration-Task Load Index (workload). RESULTS Significant differences were detected for SDM scores for scenarios 1 (192 vs 278; P = .01) and 3 (129 vs 225; P = .004), operating room communication assessment (67 vs 91; P = .002), and line operations safety audits (58 vs 87; P = .001), but not for time-out (46 vs 51) or scenario 2 SDM score (301 vs 322). Workload was similar for both groups and face validity (8.8 on a 10-point scale) was strongly supported. CONCLUSIONS Objective decision-making scoring for 2 of 3 scenarios and communication and teamwork ratings showed construct validity. Face validity and participant feedback were excellent.

Laparoscopic choledochojejunostomy via PTFE-covered stent successfully achieves internal drainage of common bile duct obstruction

As the 80-hour work week impacts training that occurs in the operating room, and as Residency Review Committees seek evidence of how skills are taught, there is a need to focus on innovative strategies and methodologies that are being employed. This section on Surgical Education will periodically highlight Surgical Skills Centers, their experiences in training, and new technology. We welcome the opportunity to share the innovative work that you are doing. If you would like to have your center showcased, please contact Dr Kimberly Anderson at .