Troy Reihsen

Introduction and validation of the American Urological Association Basic Laparoscopic Urologic Surgery skills curriculum.

BACKGROUND AND PURPOSE The Fundamentals of Laparoscopic Surgery (FLS(™)) skills curriculum has validity evidence supporting use for assessing laparoscopic skills for general surgeons. As charged by the American Urological Association (AUA) Laparoscopy, Robotic, and New Surgical Technology Committee, we sought to develop and validate a urology-specific FLS, referred to as the Basic Laparoscopic Urologic Surgery (BLUS(©)) skills curriculum. The psychomotor component consists of three existing FLS tasks and one new clip-applying task. MATERIALS AND METHODS An animate renal artery model was designed for a clip-applying skills task. We assessed the acceptability and construct validity of using BLUS for basic laparoscopic skills assessment for urologists. A cohort of practicing urologists, fellows, residents, and medical students completed the tasks at the AUA Annual Meetings in 2010 and 2011. RESULTS All exercises were acceptable and demonstrated excellent face and content validity (>4.5/5 on a five-point Likert scale). Practicing clinical urologists (N=81) outperformed residents and medical students (N=35) in time to completion of circle cut (P<0.01) and in keeping scissor tips toward the center of the circle (P<0.01). Practicing urologists who reported >3 laparoscopic procedures per week were faster at the peg-transfer exercise (P<0.05) and the cutting exercise (P<0.01) than those reporting one to two procedures. More errors were committed for clip-applying among practicing urologists who perform one to two laparoscopic procedures (1.24) vs. those who perform >3 procedures (0.57) per week (P<0.01). CONCLUSIONS All exercises including the novel clip-applying model demonstrated good acceptability and evidence of construct validity (face, content, concurrent and convergent validity) for assessment of basic laparoscopic skill for urologic surgeons.

Psychomotor skills training in pediatric airway endoscopy simulation

Objective. To develop a robust psychomotor skills curriculum to teach pediatric airway foreign body retrieval and to assess the effect of this curriculum on residents’ confidence in and ability to perform the complete task in an infant airway mannequin. Study Design. Instructional course. Objective Structured Assessment of Technical Skills (OSATS). Setting. Surgical simulation laboratory. Subjects and Methods. A half-day simulation-based course was developed to train otolaryngology residents in bronchoscopic foreign body retrieval. This complex psychomotor skill was deconstructed into subtasks. The following curricular learning objectives were presented and assessed: understanding of tracheobronchial anatomy, ability to adequately visualize the larynx with laryngoscopy, proficiency in rigid bronchoscopy, and familiarity with foreign body instrumentation. Residents were objectively evaluated on their ability to perform the complete task on a simulator before and after the course using an OSATS grading system. Confidence in successfully assembling the instruments and completing the task was assessed at these time periods. Results. Seventeen otolaryngology residents completed the study. Confidence in assembling the instruments and in performing the complete task increased on average by 81% and 43%, respectively (P < .001). Using a 15-point OSATS grading system, the average score for the precourse was 7 and for the postcourse was 11.3 (P < .001). Conclusion. Simulation-based subtask training shows promise as an effective and reproducible method to teach the complex psychomotor task of airway foreign body retrieval. Completion of the curriculum led to a significant improvement in residents’ confidence in and ability to perform bronchoscopic foreign body retrieval in an infant airway mannequin.

Task deconstruction facilitates acquisition of transurethral resection of prostate skills on a virtual reality trainer.

AIM To determine whether task deconstruction is superior to full-task training for the acquisition of transurethral resection skills on a transurethral resection of prostate (TURP) virtual reality trainer previously validated for use in residency training. METHODS Eighteen first- and second-year medical students with no previous exposure to TURP in the operating room participated in the study. The subjects were randomized to two treatment arms: full-task TURP training versus task deconstruction training. A 5-minute full-task exercise was done as a pretest and posttest in both groups. Training time was held constant at 45 minutes for both groups. The first group practiced the full-task resection for 45 minutes, while the second group performed four deconstructed tasks for a total of 45 minutes. This comprised of cystoscopy and identification of anatomy, coagulation, cutting, and complete resection exercises. Statistical analysis was performed by the Mann-Whitney test. RESULTS There was a significant difference in improvement comparing the pretest and posttest performance between the two groups, favoring task deconstruction over full-task training in the amount of tissue resected and grams resected/time on cutting pedal. There was no significant difference noted in number of bleeders coagulated, fluid consumed/gram resected, or bleeders coagulated/time on coagulation pedal. There was no difference in perforation rate between two groups. The mean approval rating of the curricular experience on the simulator was 4.0/5.0 in the task deconstruction group and 3.1/5.0 in the case of the full-task training group. CONCLUSION For the acquisition of transurethral resection skills, task deconstruction is superior to full-task training alone, in training novices on the virtual reality TURP trainer. Such a study provides more validity evidence to the unique value of simulation in the urology minimally invasive curriculum.

Validity and Acceptability of a High-Fidelity Physical Simulation Model for Training of Laparoscopic Pyeloplasty

PURPOSE The objective was to determine the acceptability and preliminary construct validity for a high-fidelity synthetic renal pelvis/ureter tissue analogue model for use as a simulation model for training of laparoscopic pyeloplasty. MATERIALS AND METHODS The pyeloplasty model was designed with incorporated assessment lines for use in post-task Black Light Assessment of Surgical Technique (BLAST)™. Practicing urologists participating in the 2011 and 2012 American Urological Association Mentored Renal Laparoscopy courses performed a simulated laparoscopic pyeloplasty procedure and completed a post-task evaluation of the model. RESULTS Practicing urologists found the model acceptable and rated the model favorably in terms of content and face validity. Urologists who had performed a laparoscopic pyeloplasty procedure in the last 5 years outperformed those who had not by demonstrating increased patency (P<0.05), decreased twisting (P<0.05), and decreased leakage (P<0.10) at the anastomosis. CONCLUSIONS The BLAST™ pyeloplasty model demonstrated evidence of acceptability and content, face, and construct validity for training practicing urologists to perform laparoscopic pyeloplasty.

Multi-Institutional Validation of an OSATS for the Assessment of Cystoscopic and Ureteroscopic Skills

PURPOSE We evaluated the internal and construct validity of an assessment tool for cystoscopic and ureteroscopic cognitive and psychomotor skills at a multi-institutional level. MATERIALS AND METHODS Subjects included a total of 30 urology residents at Ohio State University, Columbus, Ohio; Penn Presbyterian Medical Center, Philadelphia, Pennsylvania; and Mayo Clinic, Rochester, Minnesota. A single external blinded reviewer evaluated cognitive and psychomotor skills associated with cystoscopic and ureteroscopic surgery using high fidelity bench models. Exercises included navigation, basketing and relocation; holmium laser lithotripsy; and cystoscope assembly. Each resident received a total cognitive score, checklist score and global psychomotor skills score. Construct validity was assessed by calculating correlations between training year and performance scores (both cognitive and psychomotor). Internal validity was confirmed by calculating correlations between test components. RESULTS The median total cognitive score was 91 (IQR 86.25, 97). For psychomotor performance residents had a median total checklist score of 7 (IQR 5, 8) and a median global psychomotor skills score of 21 (IQR 18, 24.5). Construct validity was supported by the positive and statistically significant correlations between training year and total cognitive score (r = 0.66, 95% CI 0.39-0.82, p = 0.01), checklist scores (r = 0.66, 95% CI 0.35-0.84, p = 0.32) and global psychomotor skills score (r = 0.76, 95% CI 0.55-0.88, p = 0.002). The internal validity of OSATS was supported since total cognitive and checklist scores correlated with the global psychomotor skills score. CONCLUSIONS In this multi-institutional study we successfully demonstrated the construct and internal validity of an objective assessment of cystoscopic and ureteroscopic cognitive and technical skills, including laser lithotripsy.

Validated assessment tools for pediatric airway endoscopy simulation.

Objective To determine the interrater reliability and construct validity of 3 separate assessment tools for assessing trainee skills in pediatric airway endoscopy simulation. Design An Objective Structured Assessment of Technical Skills (OSATS) was developed in which examinees were asked to name and assemble the airway foreign body instruments and retrieve a foreign body from an infant airway mannequin. Each examinee’s performance was assessed in a blinded fashion by 3 pediatric otolaryngology faculty at separate residency programs using 3 assessment tools: (1) objective quantifiable measures list (eg, assists needed, forceps openings, foreign body drops), (2) 15-point OSATS checklist, and (3) Global Rating Index for Technical Skills (GRITS). Setting Otolaryngology residency program. Subjects Examinees (medical students, n = 3; otolaryngology residents, n = 17; pediatric otolaryngology faculty, n = 3) and raters (n = 3). Main Outcome Measures Interrater reliability and construct validity. Results Anonymized split-screen videos simultaneously capturing each examinee’s instrument handling and the endoscopic videos were created for all 23 examinees. Nineteen videos were chosen for review by 3 raters. The interrater reliability as measured by the intraclass correlation for objective quantifiable measures ranged from 0.46 to 0.98. The intraclass correlation coefficient was 0.95 for the 15-point OSATS checklist and 0.95 for the GRITS; both showed a high degree of construct validity with scores correlating with previous experience. Conclusion Assessment tools for skills assessments must have high interrater reliability and construct validity. When assessing trainee skills in pediatric airway foreign body scenarios, the 15-point OSATS checklist developed by this group or the GRITS meets these criteria.

Feasibility of a perfused and ventilated cadaveric model for assessment of lifesaving traumatic hemorrhage and airway management skills.

BACKGROUND Training health care providers to manage common life-threatening traumatic injuries is an important endeavor. A fresh perfused cadaveric model with high anatomic and tissue fidelity was developed to assess performance of hemorrhage and airway management skills during a simulated polytrauma scenario. METHODS Fresh human cadavers were obtained within 96 hours of death. Hemorrhage from a right traumatic amputation and left inguinal wound was simulated using cannulation of the right popliteal and left femoral artery, respectively. The thoracic aorta (thoracotomy method) or external iliac arteries (Pfannenstiel method) were used for catheter access points. Lung ventilation to simulate chest rise and fall was achieved using bilateral chest tubes connected to a bag valve mask. Participants underwent a simulated nighttime field care scenario in which they attempted tourniquet placement, direct wound pressure and packing, and endotracheal intubation. RESULTS Twenty-four donors were obtained (58–95 years old; mean, 77). There were 305 total scenarios completed using 23 cadavers (mean, approximately 13 scenarios per cadaver). The cost for acquisition and preparation of donors can be estimated at

The SimPORTAL fluoro-less C-arm trainer: an innovative device for percutaneous kidney access.

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Exploratory Visualization of Surgical Training Databases for Improving Skill Acquisition

9,399. CONCLUSION This model successfully allowed for the demonstration of hemorrhage and airway management skills with high anatomic and tissue fidelity. For the assessment of critical lifesaving skills that are nondestructive in nature, the use of a fresh perfused cadaveric model is feasible and suitable for evaluation of these procedures.

Evidence for a Role of Nerve Injury in Painful Intervertebral Disc Degeneration: A Cross-Sectional Proteomic Analysis of Human Cerebrospinal Fluid

INTRODUCTION AND OBJECTIVES Achieving proper renal access is arguably the most challenging component of percutaneous nephrolithotomy. A core skill required during this procedure is the use of C-arm fluoroscopic imaging and parallax techniques for proper needle insertion into a predetermined calyceal papilla. The trainers available for these skills include virtual reality (VR) simulators and physical models requiring actual fluoroscopy and radiation exposure precautions. In this study we present the successful proof-of-concept of a low-cost physical fluoro-less C-arm trainer (CAT) for training percutaneous renal access. MATERIALS AND METHODS The SimPORTAL CAT includes a mini C-arm for simulating fluoroscopic imaging and a silicon flank simulation model for needle insertion. The C-arm has two mounted video cameras and is jointed to tilt and rainbow. The flank model contains an anatomically accurate cast of the upper urinary tract, including the ureter, calyces, and the renal pelvis, with an overlay of ribs to visually and tactically simulate the 10th-12th ribs. The simulated fluoroscopic imaging is viewed on a computer screen allowing for real-time visualization. Preliminary surveys were completed by participants (n=14) at a training course that took place in Hemel Hampsted to obtain information on the acceptability of version 2.1 of the model. RESULTS We have successfully created a fluoro-less CAT that achieves the goals of training percutaneous access of the kidney. All participants (100%) considered the concept of avoiding radiation exposure during training as a highly valuable feature. About 92.8% of the enrolled participants considered the CAT of at least equal value to existing VR training models. CONCLUSIONS The fluoroscopy-less CAT is an economically feasible and accurate model for training parallax. It effectively replicates the functions of a C-arm X-ray system for percutaneous access to the kidney without any radiation exposure to the learner. Further studies will examine construct validity for training and assessing percutaneous access skills.