Opportunity to Perform - Should Simulation-Based Surgical Training be Provided on Demand or on Supply?

Introduction: The aim of the study was to assess the surgical case volume of residents before and after simulation-based training in hip fracture surgery provided on demand versus knee and shoulder arthroscopy provided on supply. Materials and Methods: A retrospective analysis of surgical case volume in hip fracture surgery and arthroscopic shoulder and knee procedures 90 days before and after simulation-based training of either procedure. Sixty-nine orthopedic residents voluntarily participating in either simulation-based training. Hip fracture surgery simulation was provided on supply, ie, whenever 1-2 residents applied for the course, while the arthroscopic simulation course was supplied twice yearly. Results: Thirty-four residents participated in hip fracture simulation on demand and 35 residents participated in arthroscopic simulation on supply. The surgical case volume of hip fracture osteosynthesis increased from median 2.5 (range: 0-21) to median 11.5 (1-17) from 90 days before to the 90 days after the simulation-based training on demand. The median difference was 6.5 procedures (p < 0.0003). On the contrary, the surgical case volume in shoulder and knee arthroscopy was low both before and after the simulation on supply, ie, median 2 (0-22) before and median 1 (0-31) after. The median difference was 0 (p = 0.21). Conclusions: Simulation on demand was associated with increased opportunities to perform in the clinical environment after the simulation-based training compared with simulation on supply. Simulation-based training should be aligned with the clinical rotation of the residents. Simulation on demand instead of supply on fixed dates may overcome this organizational issue of aligning training with the opportunity to perform.

Technical, Non-Technical, or Both? A Scoping Review of Skills in Simulation-Based Surgical Training.

OBJECTIVE: Technical and non-technical skills are traditionally investigated separately in simulation-based surgical training (SBST). Recent literature has indicated an interrelation of these skills, but a clear relationship is yet to be established. This scoping review aimed to identify published literature on the use of both technical and non-technical learning objectives in SBST and investigate how the entities are related. Additionally, this scoping study reviewed the literature with the aim of mapping how publications on technical and non-technical skills within SBST have changed over time. DESIGN: We conducted a scoping review using the 5 step framework by Arksey and O'Malley and reported our results according to the PRISMA guidelines for scoping reviews. Four databases, PubMed, Web of Science, Embase and Cochrane Library, were systematically searched for empirical studies on SBST. Studies within surgical training addressing both technical and non-technical learning objectives and presenting primary data were included for further analysis. RESULTS: Our scoping review identified 3144 articles on SBST published between 1981 and 2021. During our analysis, an emphasis on technical skills training in published literature was identified. However, recent years have seen an immense increase of publications within either technical or non-technical skills. A similar trend is seen in publications addressing both technical and non-technical. In total, 106 publications addressed both technical and non-technical learning objectives and were included for further analysis. Only 45 of the included articles addressed the relationship between technical and non-technical skills. These articles mainly focused on the effect of non-technical skills on technical skills. CONCLUSIONS: Though literature on the relationship between technical and non-technical skills remains scarce, the included studies on technical skills and non-technical skills such as mental training suggest such a relationship exists. This implies that the separation of the skill sets is not necessarily beneficial for the outcome of SBST. A shift towards seeing technical and non-technical skills as intertwined may enhance learning outcomes from SBST.

Ticket to perform: an explorative study of trainees' engagement in and transfer of surgical training.

BACKGROUND: Research suggests that simulation-based surgical skills training translates into improved operating room performance. Previous studies have predominantly focused on training methods and design and subsequent assessable performances and outcomes in the operating room, which only covers some aspects of training engagement and transfer of training. The purpose of this qualitative study was to contribute to the existing body of literature by exploring characteristics of first-year trainees' engagement in and perceptions of transfer of surgical skills training. METHODS: We conducted an explorative study based on individual interviews with first-year trainees in General Surgery, Urology, and Gynaecology and Obstetrics who participated in a laparoscopic skills training program. Informants were interviewed during and two months after the training program. A thematic cross-case analysis was conducted using systematic text condensation. RESULTS: We interviewed 12 informants, which produced 24 transcripts for analysis. We identified four main themes: (1) sportification of training, (2) modes of orientation, (3) transferrable skills, and (4) transfer opportunities. Informants described their surgical training using sports analogies of competition, timing, and step-by-step approaches. Visual orientations, kinaesthetic experiences, and elicited dialogues characterised training processes and engagement. These characteristics were identified in both the simulated and the clinical environment. Experiences of specific skills transfer included ambidexterity, coordination, instrument handling, and visuospatial ability. General transfer experiences were salient in informants' altered training approaches. Informants considered the simulation-based training an entry ticket to perform in the operating room and mentioned supervisor-trainee relationships and opportunities in the workplace as critical conditions of transfer. CONCLUSIONS: Our findings elucidate characteristics of surgical training engagement that can be interpreted as self-regulated learning processes that transcend surgical training environments. Despite appreciating the immediate skills improvements resulting from training, trainees' narratives reflected a struggle to transfer their training to the clinical setting. Tensions existed between perceptions of transferable skills and experiences of transfer within the clinical work environments. These results resonate with research emphasising the importance of the work environment in the transfer process. Our findings provide insights that may inform the development of training programs that support self-regulated learning and transfer of training from the simulated to the clinical environment.

Remote training in laparoscopy: a randomized trial comparing home-based self-regulated training to centralized instructor-regulated training.

BACKGROUND: Simulation-based surgical training (SBST) is key to securing future surgical expertise. Proficiency-based training (PBT) in laparoscopy has shown promising results on skills transfer. However, time constraints and limited possibilities for distributed training constitute barriers to effective PBT. Home-based training may provide a solution to these barriers and may be a feasible alternative to centralized training in times of assembly constraints. METHODS: We randomly assigned first-year trainees in abdominal surgery, gynecology, and urology to either centralized instructor-regulated training (CIRT) or home-based self-regulated training (HSRT) in laparoscopy. All participants trained on portable box trainers providing feedback on metrics and possibility for video reviewing. Training in both groups was structured as PBT with graded proficiency exercises adopted from the Fundamentals of Laparoscopic Surgery (FLS). The HSRT group trained at home guided by online learning materials, while the CIRT group attended two training sessions in the simulation center with feedback from experienced instructors. Performance tests consisted of hand-eye and bimanual coordination, suture and knot-tying, and FLS exercises. We analyzed passing rates, training time and distribution, and test performances. RESULTS: Passing rates were 87% and 96% in the CIRT and HSRT group, respectively. HSRT facilitated distributed training and resulted in greater variation in training times. Task times for hand-eye and bimanual coordination were significantly reduced between pretest and posttest in both groups. Trainees maintained their posttest performances at the 6-month retention test. Our analyses revealed no significant inter-group differences in performances at pretest, posttest, or retention test. Performance improvements in the two groups followed similar patterns. CONCLUSION: CIRT and HSRT in laparoscopy result in comparable performance improvements. HSRT in laparoscopy is a feasible and effective alternative to CIRT when offered inside a supportive instructional design. Further research is needed to clarify trainees' preferences and explore facilitators and barriers to HSRT.

Trainees' surgical activity and opportunity to transfer after simulation-based training.

INTRODUCTION: Simulation-based surgical training (SBST) is predicated on the assumption that trainees transfer their acquired skills and competencies into the operating room. Research on transfer of surgical training has focused on trainees' performance improvements and not on their actual opportunity to transfer their trained skills. METHODS: This was a retrospective study conducted using data on surgical procedures performed by first-year trainees in abdominal surgery, gynaecology and urology in the Central Denmark Region. We included data on trainees who participated in two different SBST courses; open surgery and laparoscopic surgery from 2014 to 2018. RESULTS: Data on a total of 127 first-year trainees were included. Our results revealed considerable variation in the number of procedures performed by first-year trainees in the three specialities. Comparing surgical activity after and before the SBST courses, we found median differences between 0 and 3, indicating no consistent increases in trainees' surgical activity in the post-course periods (five out of six comparisons were insignificant (p > 0.05)). CONCLUSIONS: Trainees' surgical exposure varies within specialities and this may have consequences for achieving uniform levels of competence among trained specialists. Our results suggest that trainees do not have timely opportunities to intensify their clinical surgical activities after participating in SBST courses. A delay in opportunities to perform may inhibit the trainee's use of acquired skills and competencies and hamper transfer of training. FUNDING: none. TRIAL REGISTRATION: not relevant.

Systematic review of the limited evidence for different surgical techniques at benign hysterectomy: A clinical guideline initiated by the Danish Health Authority.

Hysterectomy for benign gynecological conditions is a common operation that has developed extensively through the last 20 years. Methods and surgical techniques vary throughout the regions in Denmark as well as internationally. Consequently, the Danish Health Authority initiated a national clinical guideline on the subject based on a systematic review of the literature. A guideline panel of seven gynecologists formulated the clinical questions for the guideline. A search specialist performed the comprehensive literature search. The guideline panel reviewed the literature and rated the quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Finally, the panel weighted the evidence and formulated the clinical recommendations. Based on the limited available literature and the corresponding quality of evidence according to GRADE, the guideline panel gave the following recommendations: ↓ Subtotal hysterectomy should only be preferred over total hysterectomy after careful consideration because there are documented disadvantages such as persistent cyclic vaginal bleeding (⊕ΟΟΟ). ↑ Consider vaginal hysterectomy rather than conventional laparoscopic hysterectomy for non-prolapsed uteri when feasible (⊕ΟΟΟ). ↓ Robot-assisted laparoscopic hysterectomy should only be preferred over conventional laparoscopic hysterectomy after careful consideration because the beneficial effect is uncertain and because of the longer operating time (⊕⊕ΟΟ). ↑ Consider concomitant bilateral salpingectomy at the time of hysterectomy if the procedure is not considered to increase the risk of complications significantly (⊕ΟΟΟ). ↑ Consider vaginal vault suspension to the cardinal and the uterosacral ligaments when performing hysterectomy for non-prolapsed uteri (⊕ΟΟΟ). Though supporting evidence is missing, the guideline panel emphasizes that it is good practice not to morcellate uteri with presumed fibroids inside the peritoneal cavity (√). The recommendations serve as professional advice in specific clinical situations. The implementation of the guideline in Denmark will be monitored through the national Danish Hysterectomy and Hysteroscopy Database.

[Patients with diagnostic challenging intestinal involvement of the endometriosis].

A considerable proportion of women with endometriosis have intestinal involvement of the endometriosis. Intestinal endometriosis (IE) often results in abdominal pain and thus mimics the symptoms of other bowel diseases, including colon cancer. As a consequence, some women with IE are initially referred to general surgery and treated under suspicion of colon cancer. This case report demonstrates the diagnostic challenges and describes the key symptoms of IE. Women with key symptoms should be referred to a gynaecological department for transvaginal ultrasonography. The optimal surgical treatment for IE is laparoscopically assisted bowel resection.