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Training impact and cost efficiency of a comprehensive curriculum for advanced laparoscopic skills: A randomized controlled trial
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Surgical Forum Abstracts
lum and may be used for formative and summative feedback. The self-assessment tool may be most useful for self-guided learning, while the expert tool may be valuable for more formal assessment.
Training impact and cost efficiency of a comprehensive curriculum for advanced laparoscopic skills: A randomized controlled trial Neil Orzech MD, MEd, Richard Reznick MD, MEd, FRCSC, FACS, Oscar Henao MD, Allan Okrainec MD, MHPE, FRCSC, FACS, Teodor Grantcharov MD, PhD St. Michael’s Hospital/University of Toronto, Toronto, ON, Canada INTRODUCTION: PURPOSE: Design and validate two proficiencybased training curricula involving tools with proven validity for advanced skills training in Minimally Invasive Surgery (MIS); including transfer of these skills to the Operating Room (OR). Provide a cost analysis of the efficiency of pre-OR training. METHODS: 20 General Surgery residents with intermediate MIS experience were randomized to receive proficiency-based laparoscopic suturing (LS) training using either a virtual reality (VR) surgical simulator (Group-A), or laparoscopic trainer-box (Group-B). Post-curricular proficiency was evaluated using a LS checklist and a global rating scale during a: (1) bench-top laparoscopic fundoplication model; and (2) laparoscopic fundoplication in the OR. Intraoperative performance of six residents (Control-Group) and three MIS surgeons (Expert-Group) were included for statistical comparison. A cost-analysis was performed. RESULTS: Group-A and Group-B reached LS-proficiency after a mean of 17.81 minutes (SD⫽4.94) and 37.10 minutes (SD⫽15.76) respectively (p⬍.002). Intraoperatively, Groups A and B performed similarly for time (p⫽0.74), OSATS score (p⫽.68) and LS-checklist score (p⫽0.97). Groups A&B were significantly different than both the Control and Expert Groups for these same measures (p⬍0.05). Six intraoperative repetitions were required for Control Group subjects to achieve proficiency equivalent to Groups A&B (Friedman’s Test, p⫽0.83). The Transfer-Effectiveness-Ratio was 2.32 for Group A and 1.13 for Group B. Pre-OR training resulted in significant cost savings and better utilization of OR resources. CONCLUSIONS: Two proficiency-based LS curricula have been validated. Trainer-box and VR simulators effectively train residents to proficiency; significantly reducing the intra-operative learningcurve. VR LS training appears to be twice as effective as box-training. Adopting a simulation-based curriculum is more cost effective for North American residency programs compared to conventional intra-operative training.
Laparoscopic simulation training: When do we need a refresher? Esther M Bonrath MD, Sören T Mees MD, Barbara Weber, Heiner H Wolters MD, Norbert Senninger, FACS, Emile M Rijcken MD University Hospital Muenster, Muenster, Germany INTRODUCTION: Simulation in laparoscopy leads to skill acquisition. How long and how often training needs to be performed is
J Am Coll Surg
matter of debate. We evaluated how long acquired basic laparoscopic skills are retained by surgical novices (students) after an intensified curriculum using a boxtrainer. METHODS: 24 students underwent a curriculum consisting of 9 skills with increasing complexity graded as simple, moderate or complex. Each subject underwent baseline evaluation (BL) and reevaluation (RE) after completion of two 4 hour coaching sessions. Skill retention (SR) was measured at 6 weeks in Group A (n⫽12) and 11 weeks in Group B (n⫽12). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance. Statistics: MannWhitney U test, P⬍ 0.05 significant. RESULTS: Comparison of the BL and RE values after coaching showed a significant learning outcome (P⬍ 0.05) for all exercises in both groups. Group A: no significant differences between RE and SR results at 6 weeks for all tasks. Group B: no significant differences between SR and RE values for simple and moderate tasks, whereas a significant difference (P⬍ 0.05) with poorer performance at 11 weeks was observed for complex tasks. CONCLUSIONS: Basic laparoscopic skills can be successfully learnt by surgical novices in a compacted curriculum. These skills are retained for at least 6 weeks. At 11 weeks complex tasks are forgotten and therefore an opportunity for practice and repetition is desirable 6 - 11 weeks after skill acquisition.
Basic surgical skills testing for junior residents: Is it necessary? Hilary Sanfey MB BCh FACS, Gary Dunnington MD FACS Southern Illinois University, Springfield, IL INTRODUCTION: The ACS/APDS curriculum includes basic skills verification of proficiency.It is unclear how skills evaluation is incorporated into residency curricula, or promotion decisions. This study aims to identify perceptions of general surgery program directors (PDs) on basic skills evaluation. This information will inform the development of a national basic skills final examination. METHODS: 30 PDs were invited to participate in a telephone interview. PDs were chosen for diversity of program location, and training and asked to comment on their utilization and perceptions of skills curricula, and evaluation. RESULTS: 22 (73%)PDs agreed to participate.Only 10 (45%)PDs used the ACS/APDS Curriculum. 6 (27%) were unaware of its existence. Only 4 (18%) perform formal skills evaluation and an additional 8 (36%), provide feedback during instruction without documentation of deficiency. None prohibit resident OR participation if basic skills (knot tying/suturing)are observed to be inadequate. One institution required evidence of satisfactory central line placement skills for credentialing. 13 (60%)occasionally send residents back to the skills lab if skills are deficient in the OR. None used poor technical skills as a reason to deny resident promotion. Obstacles to evaluation included time, resources and validated tests. Additional concerns included a perception that more frequent resident deficien-
Surgical Forum Abstracts
lum and may be used for formative and summative feedback. The self-assessment tool may be most useful for self-guided learning, while the expert tool may be valuable for more formal assessment.
Training impact and cost efficiency of a comprehensive curriculum for advanced laparoscopic skills: A randomized controlled trial Neil Orzech MD, MEd, Richard Reznick MD, MEd, FRCSC, FACS, Oscar Henao MD, Allan Okrainec MD, MHPE, FRCSC, FACS, Teodor Grantcharov MD, PhD St. Michael’s Hospital/University of Toronto, Toronto, ON, Canada INTRODUCTION: PURPOSE: Design and validate two proficiencybased training curricula involving tools with proven validity for advanced skills training in Minimally Invasive Surgery (MIS); including transfer of these skills to the Operating Room (OR). Provide a cost analysis of the efficiency of pre-OR training. METHODS: 20 General Surgery residents with intermediate MIS experience were randomized to receive proficiency-based laparoscopic suturing (LS) training using either a virtual reality (VR) surgical simulator (Group-A), or laparoscopic trainer-box (Group-B). Post-curricular proficiency was evaluated using a LS checklist and a global rating scale during a: (1) bench-top laparoscopic fundoplication model; and (2) laparoscopic fundoplication in the OR. Intraoperative performance of six residents (Control-Group) and three MIS surgeons (Expert-Group) were included for statistical comparison. A cost-analysis was performed. RESULTS: Group-A and Group-B reached LS-proficiency after a mean of 17.81 minutes (SD⫽4.94) and 37.10 minutes (SD⫽15.76) respectively (p⬍.002). Intraoperatively, Groups A and B performed similarly for time (p⫽0.74), OSATS score (p⫽.68) and LS-checklist score (p⫽0.97). Groups A&B were significantly different than both the Control and Expert Groups for these same measures (p⬍0.05). Six intraoperative repetitions were required for Control Group subjects to achieve proficiency equivalent to Groups A&B (Friedman’s Test, p⫽0.83). The Transfer-Effectiveness-Ratio was 2.32 for Group A and 1.13 for Group B. Pre-OR training resulted in significant cost savings and better utilization of OR resources. CONCLUSIONS: Two proficiency-based LS curricula have been validated. Trainer-box and VR simulators effectively train residents to proficiency; significantly reducing the intra-operative learningcurve. VR LS training appears to be twice as effective as box-training. Adopting a simulation-based curriculum is more cost effective for North American residency programs compared to conventional intra-operative training.
Laparoscopic simulation training: When do we need a refresher? Esther M Bonrath MD, Sören T Mees MD, Barbara Weber, Heiner H Wolters MD, Norbert Senninger, FACS, Emile M Rijcken MD University Hospital Muenster, Muenster, Germany INTRODUCTION: Simulation in laparoscopy leads to skill acquisition. How long and how often training needs to be performed is
J Am Coll Surg
matter of debate. We evaluated how long acquired basic laparoscopic skills are retained by surgical novices (students) after an intensified curriculum using a boxtrainer. METHODS: 24 students underwent a curriculum consisting of 9 skills with increasing complexity graded as simple, moderate or complex. Each subject underwent baseline evaluation (BL) and reevaluation (RE) after completion of two 4 hour coaching sessions. Skill retention (SR) was measured at 6 weeks in Group A (n⫽12) and 11 weeks in Group B (n⫽12). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance. Statistics: MannWhitney U test, P⬍ 0.05 significant. RESULTS: Comparison of the BL and RE values after coaching showed a significant learning outcome (P⬍ 0.05) for all exercises in both groups. Group A: no significant differences between RE and SR results at 6 weeks for all tasks. Group B: no significant differences between SR and RE values for simple and moderate tasks, whereas a significant difference (P⬍ 0.05) with poorer performance at 11 weeks was observed for complex tasks. CONCLUSIONS: Basic laparoscopic skills can be successfully learnt by surgical novices in a compacted curriculum. These skills are retained for at least 6 weeks. At 11 weeks complex tasks are forgotten and therefore an opportunity for practice and repetition is desirable 6 - 11 weeks after skill acquisition.
Basic surgical skills testing for junior residents: Is it necessary? Hilary Sanfey MB BCh FACS, Gary Dunnington MD FACS Southern Illinois University, Springfield, IL INTRODUCTION: The ACS/APDS curriculum includes basic skills verification of proficiency.It is unclear how skills evaluation is incorporated into residency curricula, or promotion decisions. This study aims to identify perceptions of general surgery program directors (PDs) on basic skills evaluation. This information will inform the development of a national basic skills final examination. METHODS: 30 PDs were invited to participate in a telephone interview. PDs were chosen for diversity of program location, and training and asked to comment on their utilization and perceptions of skills curricula, and evaluation. RESULTS: 22 (73%)PDs agreed to participate.Only 10 (45%)PDs used the ACS/APDS Curriculum. 6 (27%) were unaware of its existence. Only 4 (18%) perform formal skills evaluation and an additional 8 (36%), provide feedback during instruction without documentation of deficiency. None prohibit resident OR participation if basic skills (knot tying/suturing)are observed to be inadequate. One institution required evidence of satisfactory central line placement skills for credentialing. 13 (60%)occasionally send residents back to the skills lab if skills are deficient in the OR. None used poor technical skills as a reason to deny resident promotion. Obstacles to evaluation included time, resources and validated tests. Additional concerns included a perception that more frequent resident deficien-