- Email: [email protected]
What are the Training Gaps for Acquiring Laparoscopic Suturing Skills?
ORIGINAL REPORTS
What are the Training Gaps for Acquiring Laparoscopic Suturing Skills?$ Ghada Enani, MBBS, MEd, Yusuke Watanabe, MD, PhD, Katherine M. McKendy, MD, MEd, Elif Bilgic, BSc, Liane S. Feldman, MD, Gerald M. Fried, MD and Melina C. Vassiliou, MD, MEd Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada INTRODUCTION: Advanced laparoscopic suturing is considered a challenging skill to acquire. The aim of this study was to investigate the learning process for advanced laparoscopic suturing in the operating room to understand the obstacles trainees face when trying to master the skill.
COMPETENCIES: Medical Knowledge, Practice Based
METHODS: A qualitative methodology using semistructured interviews and field observations was used. Data were analyzed using a Grounded Theory approach. Participants were general surgery residents and surgeons with advanced minimally invasive surgery (MIS) experience.
Mastery of advanced laparoscopic suturing skills requires the surgeon to overcome a steep learning curve and is essential for performing complex procedures. Previous research identified deficits in advanced laparoscopic operating room (OR) experience.1,2 This is in part due to the fact that training for these skills within a framework of a surgical residency is difficult due to limited exposure to cases that require laparoscopic suturing24 and lack of standardized teaching of advanced minimally invasive surgery (MIS).5,6 A national survey on general surgery trainees’ perceptions of laparoscopic procedures reported that although 90% of residents felt comfortable performing basic laparoscopic procedures, only 8% stated they could perform advanced procedures by the end of their training.5 Despite having passed the Fundamentals of Laparoscopic Surgery (FLS) course, over half of general surgery graduates beginning subspecialty training were considered by Fellowship Program Directors to be unable to independently perform laparoscopic suturing in the clinical environment.7 A needs assessment for advanced laparoscopic skills found that 77% of respondents felt that laparoscopic suturing training should be improved.6 Despite evidence supporting the use of simulation to acquire basic MIS skills,8-11 using simulation for advanced laparoscopic suturing is more challenging and not as well studied.4,5 Moreover, issues with laparoscopic suturing training, such as skill maintenance,12 different opinions on what should be included in curricula, and how to integrate them into a surgical residency remain unresolved.2,13-15 Thus, there is a need for such curricula to be further refined and implemented to increase the number of individuals who are competent to perform laparoscopic suturing under the realistic conditions of advanced laparoscopic procedures.
RESULTS: Ten MIS surgeons across different institutions
and 15 local general surgery residents were interviewed. The semistructured interviews and field observations of 9 advanced MIS operations (27 h) yielded the following 6 themes around the acquisition of laparoscopic suturing skills for residents: complexity, training misalignment, variability of opportunities, inconsistency of techniques, lack of feedback, and differing expectations. CONCLUSION: There are several unmet training needs
around laparoscopic suturing skills. Training for advanced laparoscopic skills requires more emphasis on coaching and the development of advanced models. This study heralded the need to incorporate advanced laparoscopic skills into the surgical simulation curriculum. ( J Surg Ed ]:]]]-]]]. Crown C 2016 Published by Elsevier Inc. on behalf of Copyright J the Association of Program Directors in Surgery. All rights reserved.) KEY WORDS: laparoscopic suturing, surgical education,
surgical simulation, resident, advanced laparoscopy
☆ Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Correspondence: Inquiries to Ghada Enani, MBBS, MEd, Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Centre, Montreal, Quebec, Canada; e-mail: [email protected]
Learning and Improvement
INTRODUCTION
Journal of Surgical Education Crown Copyright & 2016 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery. 1931-7204/$30.00 All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.12.004
1
Minimal research attention has been directed toward examining how surgical residents are learning these skills in the real-life environment and what their training needs are in advanced laparoscopic suturing. The purpose of this qualitative study was to explore the training process that takes place in the OR and the skills laboratory to teach and learn advanced laparoscopic suturing skills, as well as to identify training gaps. The results of this study will help to identify the essential components of a structured training curriculum for advanced laparoscopic suturing.
METHODS Study Design The study design is based on a qualitative methodology using semistructured interviews and field observations to explore the learning process for advanced laparoscopic suturing skills. The design was then used to generate a descriptive theory that is grounded in naturalistic data through a process that involved an iterative analysis of the participants’ multiple perspectives.16-18 Themes were then generated from the qualitative data. The study protocol was approved by the Research Ethics Board of McGill University. Study Subjects The participants in the study were MIS faculty, general surgery residents, and MIS fellows who were recruited through purposive sampling. MIS surgeons were sampled according to their expertise in the field and in teaching these skills to trainees. Surgical residents were senior trainees (postgraduate year 3-5) who had experience performing these tasks in the clinical environment. Data Sources
more fully explore the different dimensions of the learning process. In the cases observed, surgeons, fellows, and residents alternated in performing the procedure or the laparoscopic suturing. All cases were supervised by the attending surgeon. Data collection was continued until saturation.19 Data Analysis A thematic analysis of transcripts and field notes was performed using Grounded Theory methodology.16,17 The principal investigator and assistant researchers coded the transcripts and then analyzed them using a constant comparative approach.20,21 This process resulted in a group of codes that captured the unmet training needs for advanced laparoscopic suturing. Saturation of the data was reached when no new themes emerged from the data. The research team compared the preliminary categories each had identified and discussed discrepant categories. Continuous refinement and elaboration of the evolving themes was done throughout data collection and analysis.
RESULTS The first phase of the study involved 15-minute semistructured interviews with 10 experts in MIS from 8 institutions and 15 surgical trainees at the study institution. Field observations in the OR of 9 MIS operations over a 3month period (27 h) were included. A second set of interviews with 5 participants from the first group was conducted to explore the preliminary emergent themes and to further interpret the operative cognitive and technical events according to the iterative design of the Grounded Theory approach.22 Analysis of the emergent themes produced from the interviews and field notes in the needs assessment yielded 6 themes (Table). The central theme involved the level of complexity of the skill in the OR compared to the relative simplicity of the simulation tasks routinely available and how the training does not seem to address this. We detail below the various gaps in the current training paradigm that were described by our participants and that were identified during field observations.
The study included the following 2 phases of qualitative investigation: semistructured interviews and field observations. Interviews explored the perceptions of surgeons and trainees of expertise as it relates to teaching and learning advanced laparoscopic suturing skills. All interviews were conducted in person by the principal investigator at the participants’ workplace. Open-ended questions were used to guide the participants to explore the learning process of advanced laparoscopic suturing that takes place in the OR and the simulation laboratory, as well as the challenges that trainees and instructors face. These interviews were recorded and transcribed verbatim. To identify gaps in the training needs for advanced laparoscopic suturing, the study was in the form of simultaneous data collection, whereby the data from the first set of interviews were analyzed and the results informed the subsequent data collection for the second set of interviews and field observations. This method helped to
The complexity of performing laparoscopic suturing in the clinical environment can be categorized into different levels of difficulty that involve mastering both technical and nontechnical skills. The subthemes that involve nontechnical skills require the surgeon or the trainee to be familiar with the ergonomics in the OR, different field views, and added stressors in the clinical environment. Regarding
2
Journal of Surgical Education Volume ]/Number ] ] 2016
Complexity of the Task in the Clinical Environment
TABLE. Acquiring Laparoscopic Suturing Skills—Themes and Educational Needs. Theme Complexity of the task
Definition
Example
Inability of simulated tasks in simulation laboratory to model the complexity of performing the skills in the clinical arena in suboptimal conditions.
Misalignment of the timing Misalignment of simulation laboratory training of clinical training with with MIS clinical rotations prevents trainees simulation training from learning this technically demanding skill.
Lack of regular exposure
Lack of regular exposure to operative experience requiring laparoscopic suturing and lack of regular training for these skills in simulation laboratory.
Inconsistencies in the suturing techniques taught
Different suturing techniques used among surgeons, different techniques taught in simulation training compared to the clinical environment, and variability of the instrument used resulted in difficulties for trainees.
Lack of feedback
Teaching these skills without guided supervision or effective feedback to understand the errors and the cognitive capacity required to perform these tasks. Discrepancy between the performance metrics in simulation and those in the clinical environment.
Differing expectations
Surgeon: “So often the conditions in the OR are not ideal, and sometimes you are running a suture line not just one suture as in the FLS trainer box, which makes big differences. FLS is good for learning the basics absolutely, but, I do not know if you can say you can do one stitch in the OR after practicing in the FLS box like when you suture an anastomosis.” Surgeon: “The opportunity is haphazard in our program to regular practice and that's just an artefact of our training systems; that they [residents] may or may not be in a rotation where they get that clinical experience. They may ultimately don't have a dozen of cases during their residency where they offered the opportunity to do suturing and so it is a difficult paradigm. Most of us in this field feel that it's a really fundamental skill that everyone practicing gastrointestinal surgery should have.” Resident: “I do not routinely practice it [laparoscopic suturing], but that's purely due limited number of cases where you can actually do these skills and we did not get a lot of exposure in this area.” Surgeon: “The problem with teaching the Endo Stitch is considered a proprietary instrument and some people are adverse to that and some people do not like the idea of the Endo Stitch and some hospital cannot get the Endo Stitch by contract and also there are some cost considerations and also there are some variable to the use of that.” Resident: “In the lab, there is not usually an instructor who can articulate things that I should have been doing better so that I can understand and improve my skill.” Surgeon: “It is failing from my part because I do not really give them the outcomes metrics and I ask them to achieve.”
transfer of skills from the simulated to the clinical environment, trainees described the clinical environment as vastly more complex than the models they used to practice, such as the box trainer associated with the FLS program. The ergonomics are different and there are space and organ constraints, time pressures, and a host of other patientrelated factors that add complexity. The transition from the “ideal” simulation laboratory conditions to a less than ideal environment in the OR may also result in added stress for the trainee, and of course greater performance challenges. Surgeon: “Even if they have gone to the skills labs and have done some suturing practice in the FLS box, the ergonomics of the FLS are perfect—you stand in the middle and the angle is 601 and its lovely! But that’s not the case in the abdomen and especially, the type of patients I operate with—the morbidly obese populations—and the angles where the ergonomics are much more challenging.”
Resident: “It [laparoscopic suturing] took me a long time to perform it in the OR. It’s funny! Because I did well in the simulator and I reached the time and everything, but you know in reality it is a very difficult procedure.” Surgeon: “A lot of them [trainee] are overly confident they think that if they have done it in the FLS box they can do it in real life and often the challenge in real life is that there are other things to take care of.”
Journal of Surgical Education Volume ]/Number ] ] 2016
3
Misalignment of the Timing of Clinical Training With Simulation Training Training for these skills in the simulation laboratory was, for the most part, not aligned with clinical training. Both surgeons and trainees found the lack of a coherent curriculum in the simulation laboratory in combination with a dedicated clinical MIS rotation impaired the retention of
information and skills, as well as the ability to maintain proficiency. It seems to be challenging for trainees to plan their simulator practice around MIS cases, and consequently, they are not well prepared to perform these cases in the OR, which results in missed opportunities to perform the skills in the clinical environment. Surgeon: “The training is not aligned to the clinical schedule. I usually have residents who assist me in a case and if they have never sutured before laparoscopically or have seen it before, that is a missed opportunity for them to do it in the OR. But if they know a week before that they are coming to the OR and are going to work with me, or if they know that they are going to be doing a case that involves laparoscopic suturing, then they have gone to the skills laboratory before and practiced. Then that training opportunity is not missed.”
Lack of Regular Exposure Another factor that precluded the acquisition of these skills was the lack of opportunities for laparoscopic suturing in the OR. The limited and sporadic exposure to cases requiring advanced laparoscopic suturing added to the trainees’ inexperience and unpreparedness to perform the tasks in the clinical environment. This, in turn, may also lead to missed opportunities to suture in the OR. Fellow asking resident during Nissen fundoplication about laparoscopic suturing: “How many similar cases did you perform?” Resident: “I observed a few but have not done any. It is essential to learn but hard.” Fellow: “You have to see many cases before you do one, I am going to explain this one to guide you through it.” Surgeon: “Many residents have not seen it [laparoscopic suturing] before, so I usually do the first one and then it depends on the level of the residents and their skills.” Inconsistencies in the Technique Taught Surgical trainees found it difficult to master and retain suturing skills because they were taught a variety of techniques by different surgeons. For example, there were variations regarding whether or not to switch hands while performing the knot tying or to do a slipknot versus a surgical knot. Surgeon: “I teach in the clinical arena–modified FLS technique where we hold the suture and not the needle I generally tie more than 3 knots (6/5 knots) and we require that from the residents and depending on some circumstances we teach them in the clinical arena slip slide knot which we do not, unfortunately, have a good simulation model for.” Moreover, there were inconsistencies in the instruments used by surgeons and how the techniques taught in simulation training varied from what was actually performed 4
in the clinical environment. This resulted in some confusion and frustration. Resident: “In the FLS, we are expected to hold the needle when tying the knot, but what happens in the OR is that we are asked to hold the suture itself and not the knot to prevent organ injuries. I did not know that before… . The other thing that makes it more difficult is that some people use the regular stitch and other use Endo Stitch so you do not really feel comfortable using both.” Lack of Feedback Surgeons and residents felt that teaching laparoscopic suturing requires guided supervision and effective feedback. Surgeons believed that feedback helped residents to develop self-assessment skills, monitor their progress, and motivate them to practice. Teaching residents how to develop the appropriate clinical judgment is also necessary to perform these tasks safely, and surgeons did not feel that the training in the simulation laboratory addressed decision-making. Surgeon: “It is important when instructing the residents to have them have the opportunities to do it [laparoscopic suturing] and then pointing out the things that they need to pay attention to because I think that the problem is that they do not know what to pay attention to when they are watching. Or if they think they know how to already do it, a lot of them won’t really look at it actively and try to get anything out of observing. You have to have a structure in your mind in terms of what to look for in order to get something out of looking and I think it’s hard to learn out of a box or a simulator environment.” Different Expectations Surgeons and trainees had different performance expectations regarding advanced laparoscopic suturing skills. Performance metrics in the simulation laboratory focused on speed and accuracy, which were conveyed to the trainees as the way to master these skills. However, surgeons were more concerned with safety, clinical judgment, tissue handling, and coordination. There was then another contradiction between practice and real life which did not seem to help trainees. More often, residents felt that they did not comprehend what they were being shown by the surgeon when they modeled expert performance. Fellow: “Staff generally care about visual-spatial, knowledge, respecting tissues and not injuring other organs, while residents focused more on technical parts, such as performing a sleek knot and speed.”
DISCUSSION With the ubiquitous use of laparoscopic surgical techniques, laparoscopic suturing is an increasingly important skill for Journal of Surgical Education Volume ]/Number ] ] 2016
surgical trainees to master. Moreover, it allows surgeons to manage a wide range of complex operative situations and deal with intraoperative complications. Simulation-based training is an integral part of surgical education. It can help to improve patient safety concerns and accelerate the learning curve for surgical trainees.11,23 The FLS is a standardized program used to practice and assess laparoscopic skills.24 FLS includes 2 laparoscopic suturing tasks but is only the basic background required to prepare residents for suturing in the OR. Many of the residents who pass FLS still do not feel prepared to suture in the OR. Laparoscopic suturing is considered to be one of the most demanding techniques in laparoscopic surgery by residents. Therefore, we sought information about how residents acquire these skills and identify what the training gaps are. This study is essentially an educational needs assessment for advanced laparoscopic suturing. Through the semistructured interviews and field observations, we identified 6 areas in need of improvement in the current training for advanced laparoscopic suturing, between the clinical arena and the simulation laboratory. The study participants addressed the level of complexity that is required to master the skill of laparoscopic suturing. Laparoscopic suturing requires a combination of technical and decision-making skills, which are not always obvious in simulation training. Suturing in the OR presents more challenges than what is simulated in the current models as working with different fields of view, paying attention to adjacent organs, and tying and suturing within intraoperative space constraints. Although FLS is an effective platform on which to acquire basic skills, there is a need to develop simulation training models that build upon this foundation to reproduce a wider variety of clinical challenges. Learning and deliberate practice may be enhanced by a curriculum that allows for the acquisition of skills from basic to progressively higher levels of difficulty. As simulation-based training for basic skills has been shown to lead to better surgical skill in the OR and to enhance cognitive learning,25,26 it is essential for the trainee to master the more basic skills before going to the OR to focus on the higher-level and decision-making skills not addressed in the skills laboratory. Therefore, future training curricula should expand beyond fundamental skills to tackle trainees’ need to learn higher-order skills beyond simple psychomotor skills and spatial judgment, encompassing topics such as optimizing exposure, safe tissue handling, difficult clinical scenarios, unusual positioning, operative space constraints, and different OR ergonomics. The cognitive phase of a simulation curriculum requires deconstruction of procedures into tasks through the use of a hierarchical task analysis methodology. This allows identification of the subtasks required to perform a certain skill and can also be used to design a procedure or skill-specific assessment tool. These tools may also be used to provide feedback on skills training in the simulation laboratory. Lack of adequate feedback in the current training was a
concern of the residents that may have contributed to their lack of motivation to practice in the simulation laboratory. Interviewed surgeons believed that feedback should not only focus on teaching the technical skills but also focus on guiding the trainees’ decision-making skills in the simulation laboratory and the clinical environment. Training for laparoscopic skills has been shown to be superior in the context of a structured proficiency-based curriculum that incorporates feedback through individual supervision and the achievement of a predetermined level of performance.12,27,28 The senior residents we interviewed seem to have very little experience with advanced procedures that require suturing, such as bariatric or foregut MIS, despite a minimum of 5 years of clinical training. The limited and sporadic exposure to such cases in the OR could have had an influence on learning, motivation, and skill maintenance. Unfamiliarity with laparoscopic suturing among the interviewed trainees resulted in a decrease in the utilization of the simulation laboratory and hence, their practice. Surgeons in our study expected residents to be prepared before coming to the OR and to have developed a minimum level of automated psychomotor skill before being given opportunities to suture in the OR. If residents failed to demonstrate the necessary skills, these clinical opportunities would be lost. Our observations suggest that resident training might be improved through regular practice in the simulation laboratory during rotations where residents are expected to perform these tasks in the clinical environment. This might address the issue of misalignment between the timing of training in the clinical and simulated environment that was raised by the residents in our study. Short-course proficiency-based simulator training in laparoscopic suturing has shown to be very effective in skill acquisition without the need for prior baseline level of laparoscopic experience.12,13,28 However, ongoing training after completion of a course resulted in improved skill retention.12 A systematic review that summarizes key educational principles for effective medical simulation highlights the importance of integration of simulation into a broader educational program rather than offering it as an extraordinary or onetime activity.26 Simulation activities should be grounded in a standardized curriculum and built into learners’ normal training schedule to help residents see the value of training and its relevance to the real-life setting. It would be helpful to see the widespread utilization of these curricula in surgical residencies and the influence of longitudinal simulation curricula on skills acquisition and retention. Performance expectations varied between surgeons and trainees. Despite the value of FLS, and the rigorous evidence to support its validity as a measure of laparoscopic skills, when taken out of context, residents may assume that speed is more important than accuracy, and may prioritize this in their training. When performing these skills on a
Journal of Surgical Education Volume ]/Number ] ] 2016
5
patient, however, they learn that safety and precision are just as, if not more important than efficiency. Adding an objective assessment tool that highlights these other important skills may help to emphasize quality over speed. The challenge lies in ensuring that residents are given the opportunity to practice and further develop their skills after they acquire new skills. The varying suturing techniques and laparoscopic instruments used by different surgeons in the OR made it even more difficult for trainees to apply newly learned skills. Expanding the curriculum to include this variety, and some context for why one instrument or technique is used over the other would be beneficial.
CONCLUSIONS We find that the current training for laparoscopic skills does not adequately prepare trainees to perform advanced laparoscopic skills, such as suturing. Actual clinical practice encompasses multiple competencies, which is a point that may be neglected when surgical simulation exercises focus too narrowly on teaching technical skills. Training for advanced laparoscopic suturing requires a certain level of cognitive knowledge, motor memory, and choreography, along with technical steps, which are not being modeled with most current training tasks. Therefore, when possible, simulation exercises should incorporate other nontechnical components. Training needs to provide alignment between the clinical and simulation environments, and include feedback and performance metrics. The results of this study can be used as a framework for the development of a curriculum that focuses on advanced laparoscopic suturing skills.
REFERENCES 1. Park A, Witzke D, Donnelly M. Ongoing deficits in
Identifying the need for and content of an advanced laparoscopic skills curriculum: results of a national survey. Am J Surg. 2016;211(2):421-425. 7. Mattar SG, Alseidi AA, Jones DB, et al. General
surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-449. 8. Peters JH, Fried GM, Swanstrom LL, et al. Develop-
ment and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery. 2004;135(1):21-27. 9. Fried GM, Feldman LS, Vassiliou MC, et al. Proving
the value of simulation in laparoscopic surgery. Ann Surg. 2004;240(3):518-528. 10. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic
training on bench models: better and more cost effective than operating room experience? J Am Coll Surg. 2000;191(3):272-283. 11. Seymour NE, Gallagher AG, Roman SA, et al. Virtual
reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236(4):458-464. 12. Stefanidis D, Korndorffer JR, Markley S, Sierra R,
Scott DJ. Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg. 2006;202(4):599-603. 13. Korndorffer JR, Dunne JB, Sierra R, Stefanidis D,
Touchard CL, Scott DJ. Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg. 2005;201 (1):23-29. 14. Stefanidis D, Acker CE, Swiderski D, Heniford BT,
resident training for minimally invasive surgery. J Gastrointest Surg. 2002;6(3):501-509.
Greene FL. Challenges during the implementation of a laparoscopic skills curriculum in a busy general surgery residency program. J Surg Educ. 2008;65(1):4-7.
2. Palter VN, Orzech N, Aggarwal R, Okrainec A,
15. Chang L, Petros J, Hess DT, Rotondi C, Babineau TJ.
Grantcharov TP. Resident perceptions of advanced laparoscopic skills training. Surg Endosc. 2010;24 (11):2830-2834.
Integrating simulation into a surgical residency program. Surg Endosc. 2007;21(3):418-421.
3. Rattner DW, Apelgren KN, Eubanks WS. The need
6
6. Nepomnayshy D, Alseidi A, Fitzgib SC, Stefanidis D.
16. Charmaz K. Grounded theory: Objectivist and con-
for training opportunities in advanced laparoscopic surgery. Surg Endosc. 2001;15(10):1066-1077.
structivist methods. Denzin N, Lincoln Y, editors. Handbook of Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications;2000:509-535.
4. Chaisson P. Minimally invasive surgery training in
17. Glaser B, Strauss A. The Discovery of Grounded
Canada: a survey of general surgery program directors. Ann R Coll Physicians Surg Can. 2002;35(3):145-148.
Theory: Strategies for Qualitative Research. Chicago, IL: Aldine Publishing Company; 1967.
5. Qureshi A, Vergis A, Jimenez C, et al. MIS Training
18. Kennedy TJ, Lingard LA. Making sense of grounded
in Canada: a national survey of general surgery residents. Surg Endosc. 2011;25(9):3057-3065.
theory in medical education. Med Educ. 2006;40 (2):101-108. Journal of Surgical Education Volume ]/Number ] ] 2016
19. Morse J. The significance of saturation. Qual Health
Res. 1995;5(2):147-149. 20. Strauss A, Corbin J. Basics of Qualitative Research:
Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage Publications; 1998. 21. Kelle U. Computer-Aided Qualitative Data Analysis:
Theory, Methods and Practice. Thousand Oaks, CA: Sage Publications; 2002. 22. Emerson RM, Fretz RI, Shaw LL. Participant
observation and fieldnotes. Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L, eds. Handbook of Ethnography. London, UK: Sage Publications;2001: 352-368. 23. Vanderbilt AA, Grover AC, Pastis NJ, et al. Random-
24. Okrainec A, Soper NJ, Swanstrom LL, Fried GM.
Trends and results of the first 5 years of Fundamentals of Laparoscopic Surgery (FLS) certification testing. Surg Endosc. 2011;25(4):1192-1198.
25. Palter VN, Grantcharov T, Harvey A, Macrae HM. Ex
vivo technical skills training transfers to the operating room and enhances cognitive learning: a randomized controlled trial. Ann Surg. 2011;253(5):886-889. 26. Torkington J, Smith SGT, Rees BI, Darzi A. Skill
transfer from virtual reality to a real laparoscopic task. Surg Endosc. 2001;15(10):1076-1079. 27. Harold KL, Matthews BD, Backus CL, Pratt BL,
Heniford BT. Prospective randomized evaluation of surgical resident proficiency with laparoscopic suturing after course instruction. Surg Endosc. 2002;16 (12):1729-1731.
ized controlled trials: a systematic review of laparoscopic surgery and simulation-based training. Glob J Health Sci. 2015;7(2):310.
28. Aggarwal R, Hance J, Undre S, et al. Training junior
Journal of Surgical Education Volume ]/Number ] ] 2016
7
operative residents in laparoscopic suturing skills is feasible and efficacious. Surgery. 2006;139(6):729-734.
What are the Training Gaps for Acquiring Laparoscopic Suturing Skills?$ Ghada Enani, MBBS, MEd, Yusuke Watanabe, MD, PhD, Katherine M. McKendy, MD, MEd, Elif Bilgic, BSc, Liane S. Feldman, MD, Gerald M. Fried, MD and Melina C. Vassiliou, MD, MEd Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, Department of Surgery, McGill University Health Centre, Montreal, QC, Canada INTRODUCTION: Advanced laparoscopic suturing is considered a challenging skill to acquire. The aim of this study was to investigate the learning process for advanced laparoscopic suturing in the operating room to understand the obstacles trainees face when trying to master the skill.
COMPETENCIES: Medical Knowledge, Practice Based
METHODS: A qualitative methodology using semistructured interviews and field observations was used. Data were analyzed using a Grounded Theory approach. Participants were general surgery residents and surgeons with advanced minimally invasive surgery (MIS) experience.
Mastery of advanced laparoscopic suturing skills requires the surgeon to overcome a steep learning curve and is essential for performing complex procedures. Previous research identified deficits in advanced laparoscopic operating room (OR) experience.1,2 This is in part due to the fact that training for these skills within a framework of a surgical residency is difficult due to limited exposure to cases that require laparoscopic suturing24 and lack of standardized teaching of advanced minimally invasive surgery (MIS).5,6 A national survey on general surgery trainees’ perceptions of laparoscopic procedures reported that although 90% of residents felt comfortable performing basic laparoscopic procedures, only 8% stated they could perform advanced procedures by the end of their training.5 Despite having passed the Fundamentals of Laparoscopic Surgery (FLS) course, over half of general surgery graduates beginning subspecialty training were considered by Fellowship Program Directors to be unable to independently perform laparoscopic suturing in the clinical environment.7 A needs assessment for advanced laparoscopic skills found that 77% of respondents felt that laparoscopic suturing training should be improved.6 Despite evidence supporting the use of simulation to acquire basic MIS skills,8-11 using simulation for advanced laparoscopic suturing is more challenging and not as well studied.4,5 Moreover, issues with laparoscopic suturing training, such as skill maintenance,12 different opinions on what should be included in curricula, and how to integrate them into a surgical residency remain unresolved.2,13-15 Thus, there is a need for such curricula to be further refined and implemented to increase the number of individuals who are competent to perform laparoscopic suturing under the realistic conditions of advanced laparoscopic procedures.
RESULTS: Ten MIS surgeons across different institutions
and 15 local general surgery residents were interviewed. The semistructured interviews and field observations of 9 advanced MIS operations (27 h) yielded the following 6 themes around the acquisition of laparoscopic suturing skills for residents: complexity, training misalignment, variability of opportunities, inconsistency of techniques, lack of feedback, and differing expectations. CONCLUSION: There are several unmet training needs
around laparoscopic suturing skills. Training for advanced laparoscopic skills requires more emphasis on coaching and the development of advanced models. This study heralded the need to incorporate advanced laparoscopic skills into the surgical simulation curriculum. ( J Surg Ed ]:]]]-]]]. Crown C 2016 Published by Elsevier Inc. on behalf of Copyright J the Association of Program Directors in Surgery. All rights reserved.) KEY WORDS: laparoscopic suturing, surgical education,
surgical simulation, resident, advanced laparoscopy
☆ Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Correspondence: Inquiries to Ghada Enani, MBBS, MEd, Steinberg-Bernstein Centre for Minimally Invasive Surgery, McGill University Health Centre, Montreal, Quebec, Canada; e-mail: [email protected]
Learning and Improvement
INTRODUCTION
Journal of Surgical Education Crown Copyright & 2016 Published by Elsevier Inc. on behalf of the Association of Program Directors in Surgery. 1931-7204/$30.00 All rights reserved. http://dx.doi.org/10.1016/j.jsurg.2016.12.004
1
Minimal research attention has been directed toward examining how surgical residents are learning these skills in the real-life environment and what their training needs are in advanced laparoscopic suturing. The purpose of this qualitative study was to explore the training process that takes place in the OR and the skills laboratory to teach and learn advanced laparoscopic suturing skills, as well as to identify training gaps. The results of this study will help to identify the essential components of a structured training curriculum for advanced laparoscopic suturing.
METHODS Study Design The study design is based on a qualitative methodology using semistructured interviews and field observations to explore the learning process for advanced laparoscopic suturing skills. The design was then used to generate a descriptive theory that is grounded in naturalistic data through a process that involved an iterative analysis of the participants’ multiple perspectives.16-18 Themes were then generated from the qualitative data. The study protocol was approved by the Research Ethics Board of McGill University. Study Subjects The participants in the study were MIS faculty, general surgery residents, and MIS fellows who were recruited through purposive sampling. MIS surgeons were sampled according to their expertise in the field and in teaching these skills to trainees. Surgical residents were senior trainees (postgraduate year 3-5) who had experience performing these tasks in the clinical environment. Data Sources
more fully explore the different dimensions of the learning process. In the cases observed, surgeons, fellows, and residents alternated in performing the procedure or the laparoscopic suturing. All cases were supervised by the attending surgeon. Data collection was continued until saturation.19 Data Analysis A thematic analysis of transcripts and field notes was performed using Grounded Theory methodology.16,17 The principal investigator and assistant researchers coded the transcripts and then analyzed them using a constant comparative approach.20,21 This process resulted in a group of codes that captured the unmet training needs for advanced laparoscopic suturing. Saturation of the data was reached when no new themes emerged from the data. The research team compared the preliminary categories each had identified and discussed discrepant categories. Continuous refinement and elaboration of the evolving themes was done throughout data collection and analysis.
RESULTS The first phase of the study involved 15-minute semistructured interviews with 10 experts in MIS from 8 institutions and 15 surgical trainees at the study institution. Field observations in the OR of 9 MIS operations over a 3month period (27 h) were included. A second set of interviews with 5 participants from the first group was conducted to explore the preliminary emergent themes and to further interpret the operative cognitive and technical events according to the iterative design of the Grounded Theory approach.22 Analysis of the emergent themes produced from the interviews and field notes in the needs assessment yielded 6 themes (Table). The central theme involved the level of complexity of the skill in the OR compared to the relative simplicity of the simulation tasks routinely available and how the training does not seem to address this. We detail below the various gaps in the current training paradigm that were described by our participants and that were identified during field observations.
The study included the following 2 phases of qualitative investigation: semistructured interviews and field observations. Interviews explored the perceptions of surgeons and trainees of expertise as it relates to teaching and learning advanced laparoscopic suturing skills. All interviews were conducted in person by the principal investigator at the participants’ workplace. Open-ended questions were used to guide the participants to explore the learning process of advanced laparoscopic suturing that takes place in the OR and the simulation laboratory, as well as the challenges that trainees and instructors face. These interviews were recorded and transcribed verbatim. To identify gaps in the training needs for advanced laparoscopic suturing, the study was in the form of simultaneous data collection, whereby the data from the first set of interviews were analyzed and the results informed the subsequent data collection for the second set of interviews and field observations. This method helped to
The complexity of performing laparoscopic suturing in the clinical environment can be categorized into different levels of difficulty that involve mastering both technical and nontechnical skills. The subthemes that involve nontechnical skills require the surgeon or the trainee to be familiar with the ergonomics in the OR, different field views, and added stressors in the clinical environment. Regarding
2
Journal of Surgical Education Volume ]/Number ] ] 2016
Complexity of the Task in the Clinical Environment
TABLE. Acquiring Laparoscopic Suturing Skills—Themes and Educational Needs. Theme Complexity of the task
Definition
Example
Inability of simulated tasks in simulation laboratory to model the complexity of performing the skills in the clinical arena in suboptimal conditions.
Misalignment of the timing Misalignment of simulation laboratory training of clinical training with with MIS clinical rotations prevents trainees simulation training from learning this technically demanding skill.
Lack of regular exposure
Lack of regular exposure to operative experience requiring laparoscopic suturing and lack of regular training for these skills in simulation laboratory.
Inconsistencies in the suturing techniques taught
Different suturing techniques used among surgeons, different techniques taught in simulation training compared to the clinical environment, and variability of the instrument used resulted in difficulties for trainees.
Lack of feedback
Teaching these skills without guided supervision or effective feedback to understand the errors and the cognitive capacity required to perform these tasks. Discrepancy between the performance metrics in simulation and those in the clinical environment.
Differing expectations
Surgeon: “So often the conditions in the OR are not ideal, and sometimes you are running a suture line not just one suture as in the FLS trainer box, which makes big differences. FLS is good for learning the basics absolutely, but, I do not know if you can say you can do one stitch in the OR after practicing in the FLS box like when you suture an anastomosis.” Surgeon: “The opportunity is haphazard in our program to regular practice and that's just an artefact of our training systems; that they [residents] may or may not be in a rotation where they get that clinical experience. They may ultimately don't have a dozen of cases during their residency where they offered the opportunity to do suturing and so it is a difficult paradigm. Most of us in this field feel that it's a really fundamental skill that everyone practicing gastrointestinal surgery should have.” Resident: “I do not routinely practice it [laparoscopic suturing], but that's purely due limited number of cases where you can actually do these skills and we did not get a lot of exposure in this area.” Surgeon: “The problem with teaching the Endo Stitch is considered a proprietary instrument and some people are adverse to that and some people do not like the idea of the Endo Stitch and some hospital cannot get the Endo Stitch by contract and also there are some cost considerations and also there are some variable to the use of that.” Resident: “In the lab, there is not usually an instructor who can articulate things that I should have been doing better so that I can understand and improve my skill.” Surgeon: “It is failing from my part because I do not really give them the outcomes metrics and I ask them to achieve.”
transfer of skills from the simulated to the clinical environment, trainees described the clinical environment as vastly more complex than the models they used to practice, such as the box trainer associated with the FLS program. The ergonomics are different and there are space and organ constraints, time pressures, and a host of other patientrelated factors that add complexity. The transition from the “ideal” simulation laboratory conditions to a less than ideal environment in the OR may also result in added stress for the trainee, and of course greater performance challenges. Surgeon: “Even if they have gone to the skills labs and have done some suturing practice in the FLS box, the ergonomics of the FLS are perfect—you stand in the middle and the angle is 601 and its lovely! But that’s not the case in the abdomen and especially, the type of patients I operate with—the morbidly obese populations—and the angles where the ergonomics are much more challenging.”
Resident: “It [laparoscopic suturing] took me a long time to perform it in the OR. It’s funny! Because I did well in the simulator and I reached the time and everything, but you know in reality it is a very difficult procedure.” Surgeon: “A lot of them [trainee] are overly confident they think that if they have done it in the FLS box they can do it in real life and often the challenge in real life is that there are other things to take care of.”
Journal of Surgical Education Volume ]/Number ] ] 2016
3
Misalignment of the Timing of Clinical Training With Simulation Training Training for these skills in the simulation laboratory was, for the most part, not aligned with clinical training. Both surgeons and trainees found the lack of a coherent curriculum in the simulation laboratory in combination with a dedicated clinical MIS rotation impaired the retention of
information and skills, as well as the ability to maintain proficiency. It seems to be challenging for trainees to plan their simulator practice around MIS cases, and consequently, they are not well prepared to perform these cases in the OR, which results in missed opportunities to perform the skills in the clinical environment. Surgeon: “The training is not aligned to the clinical schedule. I usually have residents who assist me in a case and if they have never sutured before laparoscopically or have seen it before, that is a missed opportunity for them to do it in the OR. But if they know a week before that they are coming to the OR and are going to work with me, or if they know that they are going to be doing a case that involves laparoscopic suturing, then they have gone to the skills laboratory before and practiced. Then that training opportunity is not missed.”
Lack of Regular Exposure Another factor that precluded the acquisition of these skills was the lack of opportunities for laparoscopic suturing in the OR. The limited and sporadic exposure to cases requiring advanced laparoscopic suturing added to the trainees’ inexperience and unpreparedness to perform the tasks in the clinical environment. This, in turn, may also lead to missed opportunities to suture in the OR. Fellow asking resident during Nissen fundoplication about laparoscopic suturing: “How many similar cases did you perform?” Resident: “I observed a few but have not done any. It is essential to learn but hard.” Fellow: “You have to see many cases before you do one, I am going to explain this one to guide you through it.” Surgeon: “Many residents have not seen it [laparoscopic suturing] before, so I usually do the first one and then it depends on the level of the residents and their skills.” Inconsistencies in the Technique Taught Surgical trainees found it difficult to master and retain suturing skills because they were taught a variety of techniques by different surgeons. For example, there were variations regarding whether or not to switch hands while performing the knot tying or to do a slipknot versus a surgical knot. Surgeon: “I teach in the clinical arena–modified FLS technique where we hold the suture and not the needle I generally tie more than 3 knots (6/5 knots) and we require that from the residents and depending on some circumstances we teach them in the clinical arena slip slide knot which we do not, unfortunately, have a good simulation model for.” Moreover, there were inconsistencies in the instruments used by surgeons and how the techniques taught in simulation training varied from what was actually performed 4
in the clinical environment. This resulted in some confusion and frustration. Resident: “In the FLS, we are expected to hold the needle when tying the knot, but what happens in the OR is that we are asked to hold the suture itself and not the knot to prevent organ injuries. I did not know that before… . The other thing that makes it more difficult is that some people use the regular stitch and other use Endo Stitch so you do not really feel comfortable using both.” Lack of Feedback Surgeons and residents felt that teaching laparoscopic suturing requires guided supervision and effective feedback. Surgeons believed that feedback helped residents to develop self-assessment skills, monitor their progress, and motivate them to practice. Teaching residents how to develop the appropriate clinical judgment is also necessary to perform these tasks safely, and surgeons did not feel that the training in the simulation laboratory addressed decision-making. Surgeon: “It is important when instructing the residents to have them have the opportunities to do it [laparoscopic suturing] and then pointing out the things that they need to pay attention to because I think that the problem is that they do not know what to pay attention to when they are watching. Or if they think they know how to already do it, a lot of them won’t really look at it actively and try to get anything out of observing. You have to have a structure in your mind in terms of what to look for in order to get something out of looking and I think it’s hard to learn out of a box or a simulator environment.” Different Expectations Surgeons and trainees had different performance expectations regarding advanced laparoscopic suturing skills. Performance metrics in the simulation laboratory focused on speed and accuracy, which were conveyed to the trainees as the way to master these skills. However, surgeons were more concerned with safety, clinical judgment, tissue handling, and coordination. There was then another contradiction between practice and real life which did not seem to help trainees. More often, residents felt that they did not comprehend what they were being shown by the surgeon when they modeled expert performance. Fellow: “Staff generally care about visual-spatial, knowledge, respecting tissues and not injuring other organs, while residents focused more on technical parts, such as performing a sleek knot and speed.”
DISCUSSION With the ubiquitous use of laparoscopic surgical techniques, laparoscopic suturing is an increasingly important skill for Journal of Surgical Education Volume ]/Number ] ] 2016
surgical trainees to master. Moreover, it allows surgeons to manage a wide range of complex operative situations and deal with intraoperative complications. Simulation-based training is an integral part of surgical education. It can help to improve patient safety concerns and accelerate the learning curve for surgical trainees.11,23 The FLS is a standardized program used to practice and assess laparoscopic skills.24 FLS includes 2 laparoscopic suturing tasks but is only the basic background required to prepare residents for suturing in the OR. Many of the residents who pass FLS still do not feel prepared to suture in the OR. Laparoscopic suturing is considered to be one of the most demanding techniques in laparoscopic surgery by residents. Therefore, we sought information about how residents acquire these skills and identify what the training gaps are. This study is essentially an educational needs assessment for advanced laparoscopic suturing. Through the semistructured interviews and field observations, we identified 6 areas in need of improvement in the current training for advanced laparoscopic suturing, between the clinical arena and the simulation laboratory. The study participants addressed the level of complexity that is required to master the skill of laparoscopic suturing. Laparoscopic suturing requires a combination of technical and decision-making skills, which are not always obvious in simulation training. Suturing in the OR presents more challenges than what is simulated in the current models as working with different fields of view, paying attention to adjacent organs, and tying and suturing within intraoperative space constraints. Although FLS is an effective platform on which to acquire basic skills, there is a need to develop simulation training models that build upon this foundation to reproduce a wider variety of clinical challenges. Learning and deliberate practice may be enhanced by a curriculum that allows for the acquisition of skills from basic to progressively higher levels of difficulty. As simulation-based training for basic skills has been shown to lead to better surgical skill in the OR and to enhance cognitive learning,25,26 it is essential for the trainee to master the more basic skills before going to the OR to focus on the higher-level and decision-making skills not addressed in the skills laboratory. Therefore, future training curricula should expand beyond fundamental skills to tackle trainees’ need to learn higher-order skills beyond simple psychomotor skills and spatial judgment, encompassing topics such as optimizing exposure, safe tissue handling, difficult clinical scenarios, unusual positioning, operative space constraints, and different OR ergonomics. The cognitive phase of a simulation curriculum requires deconstruction of procedures into tasks through the use of a hierarchical task analysis methodology. This allows identification of the subtasks required to perform a certain skill and can also be used to design a procedure or skill-specific assessment tool. These tools may also be used to provide feedback on skills training in the simulation laboratory. Lack of adequate feedback in the current training was a
concern of the residents that may have contributed to their lack of motivation to practice in the simulation laboratory. Interviewed surgeons believed that feedback should not only focus on teaching the technical skills but also focus on guiding the trainees’ decision-making skills in the simulation laboratory and the clinical environment. Training for laparoscopic skills has been shown to be superior in the context of a structured proficiency-based curriculum that incorporates feedback through individual supervision and the achievement of a predetermined level of performance.12,27,28 The senior residents we interviewed seem to have very little experience with advanced procedures that require suturing, such as bariatric or foregut MIS, despite a minimum of 5 years of clinical training. The limited and sporadic exposure to such cases in the OR could have had an influence on learning, motivation, and skill maintenance. Unfamiliarity with laparoscopic suturing among the interviewed trainees resulted in a decrease in the utilization of the simulation laboratory and hence, their practice. Surgeons in our study expected residents to be prepared before coming to the OR and to have developed a minimum level of automated psychomotor skill before being given opportunities to suture in the OR. If residents failed to demonstrate the necessary skills, these clinical opportunities would be lost. Our observations suggest that resident training might be improved through regular practice in the simulation laboratory during rotations where residents are expected to perform these tasks in the clinical environment. This might address the issue of misalignment between the timing of training in the clinical and simulated environment that was raised by the residents in our study. Short-course proficiency-based simulator training in laparoscopic suturing has shown to be very effective in skill acquisition without the need for prior baseline level of laparoscopic experience.12,13,28 However, ongoing training after completion of a course resulted in improved skill retention.12 A systematic review that summarizes key educational principles for effective medical simulation highlights the importance of integration of simulation into a broader educational program rather than offering it as an extraordinary or onetime activity.26 Simulation activities should be grounded in a standardized curriculum and built into learners’ normal training schedule to help residents see the value of training and its relevance to the real-life setting. It would be helpful to see the widespread utilization of these curricula in surgical residencies and the influence of longitudinal simulation curricula on skills acquisition and retention. Performance expectations varied between surgeons and trainees. Despite the value of FLS, and the rigorous evidence to support its validity as a measure of laparoscopic skills, when taken out of context, residents may assume that speed is more important than accuracy, and may prioritize this in their training. When performing these skills on a
Journal of Surgical Education Volume ]/Number ] ] 2016
5
patient, however, they learn that safety and precision are just as, if not more important than efficiency. Adding an objective assessment tool that highlights these other important skills may help to emphasize quality over speed. The challenge lies in ensuring that residents are given the opportunity to practice and further develop their skills after they acquire new skills. The varying suturing techniques and laparoscopic instruments used by different surgeons in the OR made it even more difficult for trainees to apply newly learned skills. Expanding the curriculum to include this variety, and some context for why one instrument or technique is used over the other would be beneficial.
CONCLUSIONS We find that the current training for laparoscopic skills does not adequately prepare trainees to perform advanced laparoscopic skills, such as suturing. Actual clinical practice encompasses multiple competencies, which is a point that may be neglected when surgical simulation exercises focus too narrowly on teaching technical skills. Training for advanced laparoscopic suturing requires a certain level of cognitive knowledge, motor memory, and choreography, along with technical steps, which are not being modeled with most current training tasks. Therefore, when possible, simulation exercises should incorporate other nontechnical components. Training needs to provide alignment between the clinical and simulation environments, and include feedback and performance metrics. The results of this study can be used as a framework for the development of a curriculum that focuses on advanced laparoscopic suturing skills.
REFERENCES 1. Park A, Witzke D, Donnelly M. Ongoing deficits in
Identifying the need for and content of an advanced laparoscopic skills curriculum: results of a national survey. Am J Surg. 2016;211(2):421-425. 7. Mattar SG, Alseidi AA, Jones DB, et al. General
surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors. Ann Surg. 2013;258(3):440-449. 8. Peters JH, Fried GM, Swanstrom LL, et al. Develop-
ment and validation of a comprehensive program of education and assessment of the basic fundamentals of laparoscopic surgery. Surgery. 2004;135(1):21-27. 9. Fried GM, Feldman LS, Vassiliou MC, et al. Proving
the value of simulation in laparoscopic surgery. Ann Surg. 2004;240(3):518-528. 10. Scott DJ, Bergen PC, Rege RV, et al. Laparoscopic
training on bench models: better and more cost effective than operating room experience? J Am Coll Surg. 2000;191(3):272-283. 11. Seymour NE, Gallagher AG, Roman SA, et al. Virtual
reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236(4):458-464. 12. Stefanidis D, Korndorffer JR, Markley S, Sierra R,
Scott DJ. Proficiency maintenance: impact of ongoing simulator training on laparoscopic skill retention. J Am Coll Surg. 2006;202(4):599-603. 13. Korndorffer JR, Dunne JB, Sierra R, Stefanidis D,
Touchard CL, Scott DJ. Simulator training for laparoscopic suturing using performance goals translates to the operating room. J Am Coll Surg. 2005;201 (1):23-29. 14. Stefanidis D, Acker CE, Swiderski D, Heniford BT,
resident training for minimally invasive surgery. J Gastrointest Surg. 2002;6(3):501-509.
Greene FL. Challenges during the implementation of a laparoscopic skills curriculum in a busy general surgery residency program. J Surg Educ. 2008;65(1):4-7.
2. Palter VN, Orzech N, Aggarwal R, Okrainec A,
15. Chang L, Petros J, Hess DT, Rotondi C, Babineau TJ.
Grantcharov TP. Resident perceptions of advanced laparoscopic skills training. Surg Endosc. 2010;24 (11):2830-2834.
Integrating simulation into a surgical residency program. Surg Endosc. 2007;21(3):418-421.
3. Rattner DW, Apelgren KN, Eubanks WS. The need
6
6. Nepomnayshy D, Alseidi A, Fitzgib SC, Stefanidis D.
16. Charmaz K. Grounded theory: Objectivist and con-
for training opportunities in advanced laparoscopic surgery. Surg Endosc. 2001;15(10):1066-1077.
structivist methods. Denzin N, Lincoln Y, editors. Handbook of Qualitative Research. 2nd ed. Thousand Oaks, CA: Sage Publications;2000:509-535.
4. Chaisson P. Minimally invasive surgery training in
17. Glaser B, Strauss A. The Discovery of Grounded
Canada: a survey of general surgery program directors. Ann R Coll Physicians Surg Can. 2002;35(3):145-148.
Theory: Strategies for Qualitative Research. Chicago, IL: Aldine Publishing Company; 1967.
5. Qureshi A, Vergis A, Jimenez C, et al. MIS Training
18. Kennedy TJ, Lingard LA. Making sense of grounded
in Canada: a national survey of general surgery residents. Surg Endosc. 2011;25(9):3057-3065.
theory in medical education. Med Educ. 2006;40 (2):101-108. Journal of Surgical Education Volume ]/Number ] ] 2016
19. Morse J. The significance of saturation. Qual Health
Res. 1995;5(2):147-149. 20. Strauss A, Corbin J. Basics of Qualitative Research:
Techniques and Procedures for Developing Grounded Theory. 2nd ed. Thousand Oaks, CA: Sage Publications; 1998. 21. Kelle U. Computer-Aided Qualitative Data Analysis:
Theory, Methods and Practice. Thousand Oaks, CA: Sage Publications; 2002. 22. Emerson RM, Fretz RI, Shaw LL. Participant
observation and fieldnotes. Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L, eds. Handbook of Ethnography. London, UK: Sage Publications;2001: 352-368. 23. Vanderbilt AA, Grover AC, Pastis NJ, et al. Random-
24. Okrainec A, Soper NJ, Swanstrom LL, Fried GM.
Trends and results of the first 5 years of Fundamentals of Laparoscopic Surgery (FLS) certification testing. Surg Endosc. 2011;25(4):1192-1198.
25. Palter VN, Grantcharov T, Harvey A, Macrae HM. Ex
vivo technical skills training transfers to the operating room and enhances cognitive learning: a randomized controlled trial. Ann Surg. 2011;253(5):886-889. 26. Torkington J, Smith SGT, Rees BI, Darzi A. Skill
transfer from virtual reality to a real laparoscopic task. Surg Endosc. 2001;15(10):1076-1079. 27. Harold KL, Matthews BD, Backus CL, Pratt BL,
Heniford BT. Prospective randomized evaluation of surgical resident proficiency with laparoscopic suturing after course instruction. Surg Endosc. 2002;16 (12):1729-1731.
ized controlled trials: a systematic review of laparoscopic surgery and simulation-based training. Glob J Health Sci. 2015;7(2):310.
28. Aggarwal R, Hance J, Undre S, et al. Training junior
Journal of Surgical Education Volume ]/Number ] ] 2016
7
operative residents in laparoscopic suturing skills is feasible and efficacious. Surgery. 2006;139(6):729-734.