Vanessa N. Palter

Validation of a Structured Training and Assessment Curriculum for Technical Skill Acquisition in Minimally Invasive Surgery: A Randomized Controlled Trial

Objective: To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure. Background: Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated. Methods: This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills. Results: Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027). Conclusions: Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.)

Development and validation of a comprehensive curriculum to teach an advanced minimally invasive procedure: a randomized controlled trial.

Objective: To develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. Background: Simulators have been shown to be viable systems for teaching technical skills outside the operating room; however, integration of simulation training into comprehensive curricula remains a major challenge in modern surgical education. Currently, no curricula have been described or validated for advanced laparoscopic procedures. Methods: This prospective, single-blinded randomized controlled trial allocated 25 surgical residents to receive either conventional residency training or a comprehensive training curriculum for laparoscopic colorectal surgery. The curriculum consisted of proficiency-based psychomotor training on a virtual reality simulator, cognitive training, and participation in a cadaver lab. The primary outcome measure in this study was surgical performance in the operating room. All participants performed a laparoscopic right colectomy, which was video recorded and assessed using 2 previously validated assessment tools. Secondary outcome measures were knowledge relating to the execution of the procedure, assessed with a multiple-choice test, and technical performance on the simulator. Results: Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents (global score 16.0 [14.5–18.0] versus 8.0 [6.0–14.5], P = 0.030; number of operative steps performed 16.0 [12.5–17.5] versus 8.0 [6.0–14.5], P = 0.021; procedure-specific score 71.1 [54.4–81.6] versus 51.1 [36.7–74.4], P = 0.122). Curricular-trained residents scored higher on the multiple-choice test (10 [9–11] versus 7.5 [5.3–7.5], P = 0.047), and outperformed conventionally trained residents in 7 of 8 tasks on the simulator. Conclusions: Participation in a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery results in improved technical knowledge and improved performance in the operating room compared with conventional residency training. Reg. ID#NCT 01371136.

Simulation in surgical education

In recent years, simulation has come to the foreground as a method of teaching technical skills to surgical trainees. Rapid changes in health care systems underlie the shift to simulation-based education in many countries. Pressures include a decrease in work hours for residents, a shortening of

A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trial.

Objective:To compare the effectiveness and cost of 2 ex vivo training curricula for laparoscopic suturing. Background:Although simulators have been developed to teach laparoscopic suturing, a barrier to their wide implementation in training programs is a lack of knowledge regarding their relative training benefit and their associated cost. Method:This prospective single-blinded randomized trial allocated 24 surgical residents to train to proficiency using either a virtual reality (VR) simulator or box trainer. All residents then placed intracorporeal laparoscopic stitches during a Nissen fundoplication on a patient. The operating room (OR) cases were video-recorded and technical proficiency was assessed using 2 validated tools. OR performance of both groups was compared to that of conventionally trained residents and to fellowship-trained surgeons. A cost analysis of box training, VR training, and conventional residency training across Canadian surgical programs was performed. Results:After ex vivo training, no significant differences in laparoscopic suturing in the OR were found between the 2 groups with respect to time (P = 0.74)—global rating score (P = 0.65) or checklist score (P = 0.97). It took conventionally trained residents 6 practice attempts in the OR to achieve the technical proficiency of the ex vivo trained groups (P = 0.83). VR training was more efficient than box training (transfer effectiveness ratio of 2.31 vs 1.13). The annual cost of training 5 residents on the FLS trainer box was

Ex Vivo Technical Skills Training Transfers to the Operating Room and Enhances Cognitive Learning: A Randomized Controlled Trial

11,975.00, on the VR simulator was

Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial.

77,500.00, and conventional residency training was

Development of an objective evaluation tool to assess technical skill in laparoscopic colorectal surgery: a Delphi methodology

17,380.00. Over 5 years, box training was the most cost-effective option for all programs, and VR training was more cost-effective for programs with more 10 residents. Conclusions:Training on either a VR simulator or on a box trainer significantly decreased the learning curve necessary to learn laparoscopic suturing. VR training, however, is the more efficient training modality, whereas box training the more cost-effective option.

Designing a proficiency-based, content validated virtual reality curriculum for laparoscopic colorectal surgery: a Delphi approach.

Background: Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated. Methods: We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script. Results: The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03). Conclusions: Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.

Advanced training in laparoscopic abdominal surgery: a systematic review.

Objective:The purpose of this study was to investigate whether individualized deliberate practice on a virtual reality (VR) simulator results in improved technical performance in the operating room. Background:Training on VR simulators has been shown to improve technical performance in the operating room (OR). Currently described VR curricula consist of trainees practicing the same tasks until expert proficiency is reached. It has yet to be investigated whether the individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate into the OR. Methods:This single-blinded prospective trial randomized 16 novice surgical residents to a deliberate practice (DP) group and a conventional residency training group. Both groups performed a laparoscopic cholecystectomy in the OR that was video-recorded. Technical performance of DP group residents in the OR was assessed using 3 validated assessment tools. A score of less than 60% on any component of the assessment tool resulted in the trainee practicing a specific task on the VR simulator. The DP group practiced on the simulator as per their individualized schedule. Both groups then performed another laparoscopic cholecystectomy. A blinded expert assessed the OR recordings using a validated global rating scale. Results:Although both groups had similar technical abilities preintervention [DP: median score, 13.5 (9.3–15.0); control: median score, 14.5 (9.3–17.8); P = 0.45], the DP residents had a superior technical performance postintervention [DP: median score, 17.0 (15.3–18.5); control: median score, 12.5 (7.5–14.0); P = 0.03]. Of 8 DP residents, 6 practiced 5 basic VR tasks (median 1 trial to pass), and 7 of 8 practiced 2 advanced tasks (median 4 trials to pass). Conclusions:A curriculum of deliberate individualized practice on a VR simulator improves technical performance in the OR. This has implications to greatly improve the feasibility of implementing simulation-based curricula in residency training programs, rather then having them being limited to research protocols.

A prospective study demonstrating the reliability and validity of two procedure-specific evaluation tools to assess operative competence in laparoscopic colorectal surgery

BACKGROUNDnLaparoscopic colorectal surgery (LCS) is an advanced procedure for which no objective tools exist to assess technical skill. The aim of this study was to determine expert consensus regarding items required on a rating scale for LCS, using a Delphi technique.nnnMETHODSnExperts rated the substeps of LCS from 1 to 5. Responses were returned to the panel until consensus (Cronbachs α ≥ .80) was reached. Substeps that 80% of experts rated as ≥4 were included in the final instrument.nnnRESULTSnInitially, α values were .81 for sigmoid colectomy, .77 for right (medial-to-lateral) colectomy, and .74 for the lateral-to-medial approach. In the second round, α values were .83 for medial-to-lateral right colectomy and .82 for lateral-to-medial colectomy.nnnCONCLUSIONSnThe Delphi method allowed the determination of consensus regarding the essential steps to be included in a tool designed to measure technical competence in LCS.