Surgical Simulation: Markers of Proficiency.

Surgical simulation has become an integral component of surgical training. Simulation proficiency determination has been traditionally based upon time to completion of various simulated tasks. We aimed to determine objective markers of proficiency in surgical simulation by comparing novel assessments with conventional evaluations of technical skill. Categorical general surgery residents completed 10 laparoscopic cholecystectomy modules using a high-fidelity simulator. We recorded and analyzed simulation task times, as well as number of hand movements, instrument path length, instrument acceleration, and participant affective engagement during each simulation. Comparisons were made to Objective Structured Assessment of Technical Skill (OSATS) and Accreditation Council for Graduate Medical Education Milestones, as well as previous laparoscopic experience, duration of laparoscopic cholecystectomies performed by participants, and postgraduate year. Comparisons were also made to Fundamentals of Laparoscopic Surgery task times. Spearman's rho was utilized for comparisons, significance set at >0.50. University of Missouri, Columbia, Missouri, an academic tertiary care facility. Fourteen categorical general surgery residents (postgraduate year 1-5) were prospectively enrolled. One hundred forty simulations were included. The number of hand movements and instrument path lengths strongly correlated with simulation task times (ρ 0.62-0.87, p < 0.0001), FLS task completion times (ρ 0.50-0.53, p < 0.0001), and prior real-world laparoscopic cholecystectomy experience (ρ -0.51 to -0.53, p < 0.0001). No significant correlations were identified between any of the studied markers with Accreditation Council for Graduate Medical Education Milestones, Objective Structured Assessment of Technical Skill evaluations, total previous laparoscopic experience, or postgraduate year level. Neither instrument acceleration nor participant engagement showed significant correlation with any of the conventional markers of real-world or simulation skill proficiency. Simulation proficiency, measured by instrument and hand motion, is more representative of simulation skill than simulation task time, instrument acceleration, or participant engagement.

Binkley J ，Bukoski AD ，Doty J ，Crane M ，Barnes SL ，Quick JA ... -  《-》

Surgical resident technical skill self-evaluation: increased precision with training progression.

Surgical resident ability to accurately evaluate one's own skill level is an important part of educational growth. We aimed to determine if differences exist between self and observer technical skill evaluation of surgical residents performing a single procedure. We prospectively enrolled 14 categorical general surgery residents (six post-graduate year [PGY] 1-2, three PGY 3, and five PGY 4-5). Over a 6-month period, following each laparoscopic cholecystectomy, residents and seven faculty each completed the Objective Structured Assessment of Technical Skills (OSATS). Spearman's coefficient was calculated for three groups: senior (PGY 4-5), PGY3, and junior (PGY 1-2). Rho (ρ) values greater than 0.8 were considered well correlated. Of the 125 paired assessments (resident-faculty each evaluating the same case), 58 were completed for senior residents, 54 for PGY3 residents, and 13 for junior residents. Using the mean from all OSATS categories, trainee self-evaluations correlated well to faculty (senior ρ 0.97, PGY3 ρ 0.9, junior ρ 0.9). When specific OSATS categories were analyzed, junior residents exhibited poor correlation in categories of respect for tissue (ρ -0.5), instrument handling (ρ 0.71), operative flow (ρ 0.41), use of assistants (ρ 0.05), procedural knowledge (ρ 0.32), and overall comfort with the procedure (ρ 0.73). PGY3 residents lacked correlation in two OSATS categories, operative flow (ρ 0.7) and procedural knowledge (ρ 0.2). Senior resident self-evaluations exhibited strong correlations to observers in all areas. Surgical residents improve technical skill self-awareness with progressive training. Less-experienced trainees have a tendency to over-or-underestimate technical skill.

Quick JA ，Kudav V ，Doty J ，Crane M ，Bukoski AD ，Bennett BJ ，Barnes SL ... -  《-》

Integration of Hands-On Team Training into Existing Curriculum Improves Both Technical and Nontechnical Skills in Laparoscopic Cholecystectomy.

Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery. 9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training. Tertiary care, university based teaching institution. A total of 9 general surgery residents at the intern level. The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001). Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities.

Caskey RC ，Owei L ，Rao R ，Riddle EW ，Brooks AD ，Dempsey DT ，Morris JB ，Neylan CJ ，Williams NN ，Dumon KR ... -  《-》

Effect of Continuous Motion Parameter Feedback on Laparoscopic Simulation Training: A Prospective Randomized Controlled Trial on Skill Acquisition and Retention.

To investigate the effect of motion parameter feedback on laparoscopic basic skill acquisition and retention during a standardized box training curriculum. A Lap-X Hybrid laparoscopic simulator was designed to provide individual and continuous motion parameter feedback in a dry box trainer setting. In a prospective controlled trial, surgical novices were randomized into 2 groups (regular box group, n = 18, and Hybrid group, n = 18) to undergo an identical 5-day training program. In each group, 7 standardized tasks on laparoscopic basic skills were completed twice a day on 4 consecutive days in fixed pairs. Additionally, each participant performed a simulated standard laparoscopic cholecystectomy before (day 1) and after training (day 5) on a LAP Mentor II virtual reality (VR) trainer, allowing an independent control of skill progress in both groups. A follow-up assessment of skill retention was performed after 6 weeks with repetition of both the box tasks and VR cholecystectomy. Muenster University Hospital Training Center, Muenster, Germany. Medical students without previous surgical experience. Laparoscopic skills in both groups improved significantly during the training period, measured by the overall task performance time. The 6 week follow-up showed comparable skill retention in both groups. Evaluation of the VR cholecystectomies demonstrated significant decrease of operation time (p < 0.01), path length of the left and right instrument, and the number of movements of the left and right instruments for the Hybrid group (all p < 0.001), compared to the box group. Similar results were found at the assessment of skill retention. Simulation training on both trainers enables reliable acquisition of laparoscopic basic skills. Furthermore, individual and continuous motion feedback improves laparoscopic skill enhancement significantly in several aspects. Thus, training systems with feedback of motion parameters should be considered to achieve long-term improvement of motion economy among surgical trainees.

Buescher JF ，Mehdorn AS ，Neumann PA ，Becker F ，Eichelmann AK ，Pankratius U ，Bahde R ，Foell D ，Senninger N ，Rijcken E ... -  《-》

Resident Surgeons Underrate Their Laparoscopic Skills and Comfort Level When Compared With the Rating by Attending Surgeons.

The development of operative skills during general surgery residency depends largely on the resident surgeons' (residents) ability to accurately self-assess and identify areas for improvement. We compared evaluations of laparoscopic skills and comfort level of residents from both the residents' and attending surgeons' (attendings') perspectives. We prospectively observed 111 elective cholecystectomies at the University of Michigan as part of a larger quality improvement initiative. Immediately after the operation, both residents and attendings completed a survey in which they rated the residents' operative proficiency, comfort level, and the difficulty of the case using a previously validated instrument. Residents' and attendings' evaluations of residents' performance were compared using 2-sided t tests. The University of Michigan Health System in Ann Arbor, MI. Large academic, tertiary care institution. All general surgery residents and faculty at the University of Michigan performing laparoscopic cholecystectomy between June 1 and August 31, 2013. Data were collected for 28 of the institution's 54 trainees. Attendings rated residents higher than what residents rated themselves on a 5-point Likert-type scale regarding depth perception (3.86 vs. 3.38, p < 0.005), bimanual dexterity (3.75 vs. 3.36, p = 0.005), efficiency (3.58 vs. 3.18, p < 0.005), tissue handling (3.69 vs. 3.23, p < 0.005), and comfort while performing a case (3.86 vs. 3.38, p < 0.005). Attendings and residents were in agreement on the level of autonomy displayed by the resident during the case (3.31 vs. 3.34, p = 0.85), the level of difficulty of the case (2.98 vs. 2.85, p = 0.443), and the degree of teaching done by the attending during the case (3.61 vs. 3.54, p = 0.701). A gap exists between residents' and attendings' perception of residents' laparoscopic skills and comfort level in performing laparoscopic cholecystectomy. These findings call for improved communication between residents and attendings to ensure that graduates are adequately prepared to operate independently. In the context of changing methods of resident evaluations that call for explicitly defined competencies in surgery, it is essential that residents are able to accurately self-assess and be in general agreement with attendings on their level of laparoscopic skills and comfort level while performing a case.

Alameddine MB ，Claflin J ，Scally CP ，Noble DM ，Reames BN ，Englesbe MJ ，Wong SL ... -  《-》