The joy of surgery: how gender influences surgeons' experiences.

INTRODUCTION: Burnout in medicine is an epidemic, and surgeons are not immune. Studies often focus on negative factors leading to burnout, with less emphasis on optimizing joy. The purpose of this study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, was to explore how gender may influence surgeon well-being to better inform organizational change. METHODS: The study team developed a survey with the domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. The survey was emailed to 5777 addresses on the SAGES distribution list. Results were analyzed by calculating summary statistics. RESULTS: 223 surgeons completed the survey; 62.3% identified as men, 32.3% as women, and 5.4% did not indicate gender. Female compared to male respondents were younger (41.6 vs 52.5 years) and had practiced for fewer years (8.4 vs 19.4 years). The three greatest differences in facilitators of joy were being a leader in the field, leading clinical teams, and teaching, with a > 10 percentage point difference between men/women rating these highly (score of ≥ 8). Women generally perceived less support from their institutions than men. The greatest gender difference was in support for teaching, with 52.8% of men rating this highly compared to 30.2% of women. Only 52% of women felt respected by coworkers most of the time compared to 68.3% of men. Most (96.0%) respondents (men 95.7% and women 98.6%) reported wanting more time with family and friends. CONCLUSION: This study demonstrates the complexity of the personal and professional factors that influence joy in surgery, highlight gender differences that impact joy and suggests opportunities for improved gender-based support. These results can inform potential organization-level changes and further research to better understand emerging differences in joy across gender identities.

The joy of surgery: how surgeons experience joy, time, and support.

BACKGROUND: Burnout is a crisis in medicine, and especially in surgery it has serious implications not only for physician well-being but also for patient outcomes. This study builds on previous SAGES Reimagining the Practice of Surgery Task Force work to better understand how organizations might intervene to increase the "joy in surgery." METHODS: This was a cross-sectional, descriptive study utilizing a REDCap survey with closed-ended questions for data collection across 5 domains: facilitators of joy, support for best work, time for work tasks, barriers to joy, and what they would do with more time. We calculated average scores and "percentage of respondents giving a high score" for each item. RESULTS: There were 307 individuals who started the survey; 223 completed it and were surgeons who met the inclusion criteria. The majority (85.7%) were trained in general surgery, regardless of sub-specialty. Surgeons found joy in operating and its technical skills, curing disease, patient relationships, and working with a good team. They reported usually having what they needed to deliver care. A majority felt valued and respected. Most were dissatisfied with reimbursement, perceiving it as unfair. The most commonly worked range of hours was 51-70 per week. They reported having little time for paperwork and documentation, and if they had more time, they would spend it with friends and family. CONCLUSION: Organizations should consider interventions to address the operative environment, provide appropriate staff support, and foster good teamwork. They can also consider interventions that alleviate time pressures and administrative burden while at the same time promoting sustainable workloads.

An argument-based validation study of the fundamentals of laparoscopic surgery (FLS) program.

BACKGROUND: The Fundamentals of Laparoscopy Surgery (FLS) program was launched over 15 years ago. Since then, there has been an exponential rise in advancements of laparoscopy and its uses. In response, we conducted an argument-based validation study of FLS. The purpose of this paper is to exemplify this approach to validation for surgical education researchers using FLS as an illustrative case. METHODS: The argument-based approach to validation involves three key actions: (1) developing interpretation and use arguments; (2) research; and (3) building a validity argument. Drawing from the validation study of FLS each step is exemplified. RESULTS: Qualitative and quantitative data sources from the FLS validity examination study provided evidence that both supported claims, but also generated backing for rebuttals. Some of the key findings were synthesized in a validity argument to illustrate its structure. DISCUSSION: The argument-based validation approach described numerous advantages over other validation approaches: (1) it is endorsed by the foundational documents in assessment and evaluation research; (2) its specific language of claims, inferences, warrants, assumptions and rebuttals provides a systematic and unified way to communicate both the processes and outcomes of validation; and (3) the use of logic reasoning in building the validity document clearly delineates the relationship between evidence and the inferences made to support desired uses and interpretations from assessments.

The entrustable professional activities of laparoscopic surgery: moving toward an integrated training model.

BACKGROUND: Entrustable Professional Activities (EPAs) provide the opportunity to integrate multiple competencies into meaningful units that facilitate curriculum development and assessment design. As part of the process of reviewing and enhancing the Fundamentals of Laparoscopic of Surgery (FLS) program, we used the concept of EPAs to create a framework of reference that articulates a contemporary definition of Laparoscopic Surgery (LS). METHODS: The framework of reference of LS was created with data gathered from a literature review and during series of educational retreats with subject matter experts (SMEs). Various activities were implemented during these retreats to develop the LS EPAs, their constitutive competencies, and related observable behaviors. RESULTS: Ten EPAs and associated competency descriptors (articulated as observable behaviors) specific to LS were identified. In addition, knowledge areas were associated to each EPA. DISCUSSION: A comprehensive list of EPAs for LS were identified. These EPAs will be used in the development and update of the FLS program. Further, they can be used to guide the development of curriculum, clinical teaching, and assessment in any surgical program with a laparoscopic training component. They are applicable to any level of training by defining the expected observable behaviors associated with a given level of expertise. These fundamental aspects of LS provide a common framework of reference across different surgical specialties.

Factors influencing surgeon well-being: qualitatively exploring the joy of surgery.

BACKGROUND: There has been considerable research into burnout but much less into how surgeons thrive and find joy. This study, conducted by the SAGES Reimagining the Practice of Surgery Task Force, explored factors influencing surgeon well-being, the eventual goal being translating findings into tangible changes to help restore the joy in surgery. METHODS: This was a qualitative, descriptive study. Purposive sampling ensured representation across ages, genders, ethnicities, practice types, and geographies. Semi-structured interviews were recorded and transcribed. We coded inductively, finalized the codebook by consensus, and then constructed a thematic network. Global themes formed our conclusions; organizing themes gave additional detail. Analysis was facilitated by NVivo. RESULTS: We interviewed 17 surgeons from the US and Canada. Total interview time was 15 hours. Our global and organizing themes were: Stressors (Work-life Integration, Administration-related Concerns, Time and Productivity Pressures, Operating Room Factors, and Lack of Respect). Satisfaction (Service, Challenge, Autonomy, Leadership, and Respect and Recognition). Support (Team, Personal Life, Leaders, and Institutions). Values (Professional and Personal). Suggestions (Individual, Practice, and System level). Values, stressors, and satisfaction influenced perspectives on support. Experiences of support shaped suggestions. All participants reported stressors and satisfiers. Surgeons at all stages enjoyed operating and being of service. Supports and suggestions included compensation and infrastructure, but human resources were most critical. To experience joy, surgeons needed high-functioning clinical teams, good leaders/mentors, and supportive family/social networks. CONCLUSIONS: Our results indicated organizations could (1) better understand surgeons' values, like autonomy; (2) provide more time for satisfiers, like patient relationship building; (3) minimize stressors, like time and financial pressures; and (4) at all levels focus on (4a) building teams and leaders and (4b) giving surgeons time and space for healthy family/social lives. Next steps include developing an assessment tool for individual institutions to build "joy improvement plans" and to inform surgical associations' advocacy efforts.

Validity of video-based general and procedure-specific self-assessment tools for surgical trainees in laparoscopic cholecystectomy.

INTRODUCTION: Self-review of recorded surgical procedures offers new opportunities for trainees to extend technical learning outside the operating-room. Valid tools for self-assessment are required prior to evaluating the effectiveness of video-review in enhancing technical learning. Therefore, we aimed to contribute evidence regarding the validity of intraoperative performance assessment tools for video-based self-assessment by general surgery trainees when performing laparoscopic cholecystectomies. METHODS AND PROCEDURES: Using a web-based platform, general surgery trainees in a university-based residency program submitted recorded laparoscopic cholecystectomy procedures where they acted as the supervised primary surgeon. Attending surgeons measured operative performance at the time of surgery using general and procedure-specific assessment tools [Global Operative Assessment of Laparoscopic Skills (GOALS) and Operative Performance Rating System (OPRS), respectively] and entrustability level (O-SCORE). Trainees self-evaluated their performance from video-review using the same instruments. The validity of GOALS and OPRS for trainee self-assessment was investigated by testing the hypotheses that self-assessment scores correlate with (H1) expert assessment scores, (H2) O-SCORE, and (H3) procedure time and that (H4) self-assessment based on these instruments differentiates junior [postgraduate year (PGY) 1-3] and senior trainees (PGY 4-5), as well as (H5)simple [Visual Analogue Scale (VAS) ≤ 4] versus complex cases (VAS > 4). All hypotheses were based on previous literature, defined a priori, and were tested according to the COSMIN consensus on measurement properties. RESULTS: A total of 35 videos were submitted (45% female and 45% senior trainees) and self-assessed. Our data supported 2 out of 5 hypotheses (H1 and H4) for GOALS and 3 out of 5 hypotheses (H1, H4 and H5) for OPRS, for trainee self-assessment. CONCLUSIONS: OPRS, a procedure-specific assessment tool, was better able to differentiate between groups expected to have different levels of intraoperative performance, compared to GOALS, a general assessment tool. Given the interest in video-based learning, there is a need to further develop valid procedure-specific tools to support video-based self-assessment by trainees in a range of procedures.

Implementation of entrustable professional activities into fellowship council accredited programs: a pilot project.

OBJECTIVE: The Fellowship Council (FC) is transitioning to a competency-based medical education (CBME) model, including the introduction of Entrustable Professional Activities (EPAs) for training and assessment of Fellows. This study describes the implementation process employed by the FC during a ten-month pilot project and presents data regarding feasibility and perceived value. METHODS: The FC coordinated the development of EPAs in collaboration with the sponsoring societies for Advanced GI/MIS, Bariatrics, Foregut, Endoscopy and Hepatopancreaticobiliary (HPB) fellowships encompassing the preoperative, intraoperative, and postoperative phases of care for key competencies. Fifteen accredited fellowship programs participated in this project. The assessments were collected through a unique platform on the FC website. Programs were asked to convene a Clinical Competency Committee (CCC) on a quarterly basis. The pilot group met monthly to support and improve the process. An exit survey evaluated the perceived value of EPAs. RESULTS: The 15 participating programs included 18 fellows and 106 faculty. A total of 655 assessments were initiated with 429 (65%) completed. The average (SD) number of EPAs completed for each fellow was 24(18); range 0-72. Intraoperative EPAs were preferentially completed (71%). The average(SD) time for both the fellow and faculty to complete an EPA was 27(78) hours. Engagement increased from 39% of fellows completing at least one EPA in September to 72% in December and declining to 50% in May. Entrustment level increased from 6% of EPAs evaluated as "Practice Ready" in September to 75% in June. The exit survey was returned by 63% of faculty and 72% of fellows. Overall, 46% of fellows and 74% of program directors recommended full-scale implementation of the EPA framework. CONCLUSION: A competency-based assessment framework was developed by the FC and piloted in several programs. Participation was variable and required ongoing strategies to address barriers. The pilot project has prepared the FC to introduce CBME across all FC training programs.

What are essential laparoscopic skills these days? Results of the SAGES Fundamentals of Laparoscopic Surgery (FLS) Committee technical skills survey.

INTRODUCTION: The Fundamentals of Laparoscopic Surgery (FLS) program tests basic knowledge and skills required to perform laparoscopic surgery. Educational experiences in laparoscopic training and development of associated competencies have evolved since FLS inception, making it important to review the definition of fundamental laparoscopic skills. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) assigned an FLS Technical Skills Working Group to characterize technical skills used in basic laparoscopic surgery in current practice contexts and their possible application to future FLS tests. METHODS: A group of subject matter experts defined an inventory of 65 laparoscopic skills using a Nominal Group Technique. From these, a survey was developed rating these items for importance, frequency of use, and priority for testing for FLS certification. This survey was distributed to SAGES members, recent recipients of FLS certification, and members of the Association of Program Directors in Surgery (APDS). Results were collected using a secure web-based survey platform. RESULTS: Complete data were available for 1742 surveys. Of these, 1143 comprised results for post-residency participants who performed advanced procedures. Seventeen competencies were identified for FLS testing prioritization by determining the proportion of respondents who identified them of highest priority, at median (50th percentile) of the maximum survey scale rating. These included basic peritoneal access, laparoscope and instrument use, tissue manipulation, and specific problem management skills. Sixteen could be used to show appropriateness of the domain construct by confirmatory factor analysis. Of these 8 could be characterized as manipulative tasks. Of these 5 mapped to current FLS tasks. CONCLUSIONS: This survey-identified competencies, some of which are currently assessed in FLS, with a high level of priority for testing. Further work is needed to determine if this should prompt consideration of changes or additions to the FLS technical skills test component.

The association between video-based assessment of intraoperative technical performance and patient outcomes: a systematic review.

BACKGROUND: Efforts to improve surgical safety and outcomes have traditionally placed little emphasis on intraoperative performance, partly due to difficulties in measurement. Video-based assessment (VBA) provides an opportunity for blinded and unbiased appraisal of surgeon performance. Therefore, we aimed to systematically review the existing literature on the association between intraoperative technical performance, measured using VBA, and patient outcomes. METHODS: Major databases (Medline, Embase, Cochrane Database, and Web of Science) were systematically searched for studies assessing the association of intraoperative technical performance measured by tools supported by validity evidence with short-term (≤ 30 days) and/or long-term postoperative outcomes. Study quality was assessed using the Newcastle-Ottawa Scale. Results were appraised descriptively as study heterogeneity precluded meta-analysis. RESULTS: A total of 11 observational studies were identified involving 8 different procedures in foregut/bariatric (n = 4), colorectal (n = 4), urologic (n = 2), and hepatobiliary surgery (n = 1). The number of surgeons assessed ranged from 1 to 34; patient sample size ranged from 47 to 10,242. High risk of bias was present in 5 of 8 studies assessing short-term outcomes and 2 of 6 studies assessing long-term outcomes. Short-term outcomes were reported in 8 studies (i.e., morbidity, mortality, and readmission), while 6 reported long-term outcomes (i.e., cancer outcomes, weight loss, and urinary continence). Better intraoperative performance was associated with fewer postoperative complications (6 of 7 studies), reoperations (3 of 4 studies), and readmissions (1 of 4 studies). Long-term outcomes were less commonly investigated, with mixed results. CONCLUSION: Current evidence supports an association between superior intraoperative technical performance measured using surgical videos and improved short-term postoperative outcomes. Intraoperative performance analysis using video-based assessment represents a promising approach to surgical quality-improvement.

Development of a simulation curriculum to teach and assess advanced laparoscopic suturing skills using telesimulation: a feasibility study.

BACKGROUND: Telesimulation helps overcome limitations in time and local expertise by eliminating the need for the learner and educator to be physically co-located, especially important during COVID-19. We investigated whether teaching advanced laparoscopic suturing (ALS) through telesimulation is feasible, effective, and leads to improved suturing in the operating room (OR). METHODS: In this prospective feasibility study, three previously developed 3D-printed ALS tasks were used: needle handling (NH), suturing under tension (UT), and continuous suturing (CS). General surgery residents (PGY4-5) underwent 1-month of telesimulation training, during which an expert educator at one site remotely trained residents at the other site over 2-3 teaching sessions. Trainees were assessed in the three tasks and in the OR at three time points: baseline(A1), control period(A2), and post-intervention(A3) and completed questionnaires regarding educational value and usability of telesimulation. Paired t-test was used to compare scores between the three assessment points. RESULTS: Six residents were included. Scores for UT improved significantly post-intervention A3(568 ± 60) when compared to baseline A1(416 ± 133) (p < 0.019). Similarly, scores for CS improved significantly post-intervention A3(756 ± 113) vs. baseline A1(539 ± 211) (p < 0.02). For intraoperative assessments, scores improved significantly post-intervention A3(21 ± 3) when compared to both A1(17 ± 4) (p < 0.018) and A2(18 ± 4) (p < 0.0008). All residents agreed that tasks were relevant to practice, helped improve technical competence, and adequately measured suturing skill. All residents found telesimulation easy to use, had strong educational value, and want the system to be incorporated into their training. CONCLUSION: The use of telesimulation for remotely training residents using ALS tasks was feasible and effective. Residents found value in training using the tasks and telesimulation system, and improved ALS skills in the OR. As the pandemic has caused a major structural shift in resident education, telesimulation can be an effective alternative to on-site simulation programs. Future research should focus on how telesimulation can be effectively incorporated into training programs.

Establishing validity evidence for device-assisted advanced laparoscopic suturing tasks using simulation.

BACKGROUND: Laparoscopic suturing (LS) is an essential technique required for a wide range of procedures, and it is one of the most challenging for surgical trainees to master. We designed and collected validity evidence for advanced LS tasks using an automated suturing device and evaluated the perceived educational value of the tasks. METHODS: This project was a multicentre prospective study involving McGill University, University of Toronto (UofT), and Louisiana State University (LSU) Health New Orleans. Novice (NS) and experienced (ES) surgeons performed suturing under tension (UT) and continuous suturing (CS) tasks. ES performed the tasks twice to establish proficiency benchmarks, and they were interviewed to develop formative feedback tools (FFT). Participants were assessed on completion time, error, Global Operative Assessment of Laparoscopic Skills (GOALS), and FFT. Data were analyzed using descriptive and inferential statistical methods. RESULTS: Twenty-seven participants (13 ES, 14 NS, median age 34 years; 85% male) completed the study. Eight were attending surgeons, 7 fellows, 4 PGY5, 5 PGY4, and 3 PGY3 (18 from McGill, 5 UofT, and 4 LSU). Comparing ES and NS, for UT task, ES had significantly greater task scores (570 [563-648] vs 323 [130-464], p value 0.00036) and GOALS scores (14 [13-16] vs 10 [8-12], p value 0.0038). Similarly, for CS, ES had significantly greater task scores (976 [959-1010] vs 785 [626-856], p value 0.00009) and GOALS scores (16 [12-17] vs 12.5 [8.25-15], p value 0.028). After FFTs were developed, comparing ES and NS, for both UT and CS tasks, ES had significantly greater FFT scores (UT 25 [24-26] vs 17 [14-20], p value 0.0016 and CS 30 [27-32] vs 22[17.2-25.8], p value 0.00061). CONCLUSION: In conclusion, preliminary validity evidence was provided for the tasks. Once further validity evidence is established, incorporating the tasks into the training curricula could improve trainee skills and help to meet the need for better advanced suturing models.

Defining the key skills required to perform advanced laparoscopic procedures: a qualitative descriptive study.

BACKGROUND: Simulation is widely used to teach and assess fundamental laparoscopic skills; however, program directors have reported that current simulation programs do not meet the needs for trainees and surgeons learning advanced laparoscopic procedures (ALP). The purpose of our study was to identify the key skills required to perform ALP, to serve as the basis to establish an advanced laparoscopic skills training program. METHODS: Semi-structured interviews were conducted with attending surgeons, fellows, and senior residents in general surgery, gynaecology, and urology. The questions were developed through an iterative process using relevant literature, expert opinions, and in consultation with a qualitative researcher. Interviews were conducted in person, over the phone, or by videoconference, and inductive thematic analysis was performed. RESULTS: 25 interviews were conducted with 16 attending surgeons and 9 fellows/residents from 9 institutions in Canada and USA. Twenty-one skills were identified to be important when performing ALP. The skills most commonly described by faculty were the following : (a) suturing, (b) dissection, (c) procedural expertise, (d) retraction and exposure, and (e) familiarity with relevant anatomy as viewed through the laparoscope. The skills most commonly described by trainees were the following: (a) suturing, (b) dissection, (c) procedural expertise, (d) trocar positioning, and (e) patient factors. There was a large difference between the importance the faculty attributed to the 'Retraction and Exposure' skill compared to the trainees. CONCLUSION: This study identified key skills that are important when performing ALP. In order to address the current needs of trainees/surgeons learning ALP, this work provides the building blocks for the development of an advanced laparoscopic surgery simulation program.

S116: Impact of incisional negative pressure wound therapy on surgical site infection after complex incisional hernia repair: a retrospective matched cohort study.

INTRODUCTION: Incisional negative pressure wound therapy (iNPWT) may reduce surgical site infections (SSI), which can have devastating consequences after incisional hernia repair. Few comparative studies investigate the effectiveness of this wound management strategy in this population. The objective of this study is to determine the effect of iNPWT on the incidence of SSI after complex incisional hernia repair. METHODS: All adult patients undergoing open incisional hernia repair at a single center from 2016 to 2019 were reviewed. A commercial iNPWT dressing was used at the discretion of the surgeon. Patients were grouped by type of dressing; iNPWT and standard sterile dressings (SSD). Coarsened exact matching was used to create balanced cohorts for comparison using age, sex, American Society of Anesthesiologists classification, wound classification, and surgical urgency. The primary outcome was the composite incidence of superficial and deep SSI within 30 days. Secondary outcomes included non-infectious surgical site occurrences (SSO), overall complications, length of stay (LOS), emergency department visits, and readmission at 30 days. RESULTS: 134 patients underwent complex hernia repair, with 114 patients included after matching (34 iNPWT, 51 SSD). Composite incidence of superficial and deep SSI was 19.3% (11.8% vs. 27.5%, p = 0.107), with significantly lower rates of deep SSI in patients receiving iNPWT (2.9% vs. 17.6%, p = 0.045). After accounting for residual differences between groups, iNPWT was associated with decreased incidence of composite SSI (RR 0.36, 95% CI [0.16, 0.87]). Median LOS was longer in patients with iNPWT (7 vs. 5 days, p = 0.001). There were no differences in SSO, overall complications, readmission, or emergency department visits. CONCLUSION: In patients undergoing incisional hernia repair, the use of iNPWT was associated with a lower incidence of SSI at 30 days. Future studies should focus on cost effectiveness of iNPWT, its impact on long-term hernia recurrences, and the identification of patient selection criteria in this population.

Is there a gender bias in the advancement to SAGES leadership?

BACKGROUND: The proportion of women in surgery has risen significantly yet there remains gender discrepancies in upper leadership positions in academia. Specialty societies play an important role in academic advancement but the progression of women in surgical societies has not been studied. The purpose of this study was to determine if there are gender differences in advancement within the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) leadership. METHODS: A retrospective audit of all SAGES committee members (CM) from 1992 to 2018 was performed. The overall membership gender distribution was available from 2010 to 2018. Leadership positions included Committee Chair/Co-chair, Board of Governors, and Executive Committee. Three phenomena were investigated: "pipeline," by determining the change in women CMs compared to overall membership over time; "sticky floors," by comparing advancement beyond CM by gender; "glass-ceiling," by analyzing the promotion trajectory and time to leadership positions between genders. Statistical analysis comparing trends over time was performed using Kendall-tau. RESULTS: There were 1546 surgeons who served on at least one committee during the study period. Women represented 21% of CMs, 18% of chairs/co-chairs, 16% of board members and 14% of executives, with one woman President. The proportion of women CMs has significantly increased over time from 3% in 1992 to 27% in 2018 (p-trend < 0.001). A similar proportion of women and men advanced beyond CM (17% vs. 14%, p = 0.194), with no difference in time to advancement. From 2010 to 2018, the increase in the proportion of women CMs and board members outpaced that of overall women members (p < 0.05). Women executives surpassed overall women members in 2018 (29% vs. 19%). A similar proportion of men and women "skipped ranks" to reach the Board/Executive (37% vs. 25%, p = 0.307). CONCLUSION: The proportion of women in leadership positions within SAGES is higher than in the overall membership. There were no gender differences in the advancement of CMs to leadership positions. While these data are encouraging, SAGES should continue to foster the advancement of women surgeons.

Modern era surgical outcomes of elective and emergency giant paraesophageal hernia repair at a high-volume referral center.

INTRODUCTION: Repair of giant paraesophageal hernia (PEH) has historically been associated with significant morbidity and mortality such that elective repair is only offered to symptomatic patients. Recent reports suggest modern era outcomes have improved such that elective repair may now be safer than historically thought. Furthermore, the morbidity of emergency surgery may still be significant. These changes may have important implications for patient selection for elective repair. The objectives of this study were to determine and compare modern era surgical outcomes after elective and emergency repair of giant PEHs at a high-volume tertiary care center. METHODS: A retrospective review was conducted for all Type II-IV giant PEH repairs performed between 1 January 2012 and 31 December 2017. Type 1 hiatal hernias, fundoplication for reflux, and any co-surgery other than cholecystectomy were excluded from the final analysis. Baseline patient demographics, operative details, postoperative complications within 30 days and in-hospital or 30-day mortality were tabulated from the electronic medical record. Data were reported as median (interquartile range) unless otherwise specified. RESULTS: A total of 352 cases were reviewed, of which 204 met inclusion criteria (18 emergency, 186 elective). Eight had Type II PEH, 146 had Type III, and 50 had Type IV. Median length of stay was shorter in the elective group [1 (1) day elective vs. 5 (7) days emergency, p < 0.0001], and emergency patients were less likely to return directly to their original residence at discharge (13, 72% emergency vs 185, 99.4% elective, p < 0.0001). There were significantly more major complications (Clavien-Dindo score ≥ 3) in the emergency group (5, 28% emergency vs. 10, 5% elective, p = 0.005). There were no perioperative deaths in either group. Morbidity and mortality in both groups were less than historically reported. CONCLUSIONS: Informed consent discussions and patient selection for repair of giant PEHs should reflect modern era and institution-specific outcomes.

Simulation platforms to assess laparoscopic suturing skills: a scoping review.

BACKGROUND: Laparoscopic suturing (LS) has become a common technique used in a variety of advanced laparoscopic procedures. However, LS is a challenging skill to master, and many trainees may not be competent in performing LS at the end of their training. The purpose of this review is to identify simulation platforms available for assessment of LS skills, and determine the characteristics of the platforms and the LS skills that are targeted. METHODS: A scoping review was conducted between January 1997 and October 2018 for full-text articles. The search was done in various databases. Only articles written in English or French were included. Additional studies were identified through reference lists. The search terms included "laparoscopic suturing" and "clinical competence." RESULTS: Sixty-two studies were selected. The majority of the simulation platforms were box trainers with inanimate tissue, and targeted basic suturing and intracorporeal knot-tying techniques. Most of the validation came from internal structure (rater reliability) and relationship to other variables (compare training levels/case experience, and various metrics). Consequences were not addressed in any of the studies. CONCLUSION: We identified many types of simulation platforms that were used for assessing LS skills, with most being for assessment of basic skills. Platforms assessing the competence of trainees for advanced LS skills were limited. Therefore, future research should focus on development of LS tasks that better reflect the needs of the trainees.

Assessment of surgical performance of laparoscopic benign hiatal surgery: a systematic review.

BACKGROUND: Operative skills correlate with patient outcomes, yet at the completion of training or after learning a new procedure, these skills are rarely formally evaluated. There is interest in the use of summative video assessment of laparoscopic benign foregut and hiatal surgery (LFS). If this is to be used to determine competency, it must meet the robust criteria established for high-stakes assessments. The purpose of this review is to identify tools that have been used to assess performance of LFS and evaluate the available validity evidence for each instrument. METHODS: A systematic search was conducted up to July 2017. Eligible studies reported data on tools used to assess performance in the operating room during LFS. Two independent reviewers considered 1084 citations for eligibility. The characteristics and testing conditions of each assessment tool were recorded. Validity evidence was evaluated using five sources of validity (content, response process, internal structure, relationship to other variables, and consequences). RESULTS: There were six separate tools identified. Two tools were generic to laparoscopy, and four were specific to LFS [two specific to Nissen fundoplication (NF), one heller myotomy (HM), and one paraesophageal hernia repair (PEH)]. Overall, only one assessment was supported by moderate evidence while the others had limited or unknown evidence. Validity evidence was based mainly on internal structure (all tools reporting reliability and item analysis) and content (two studies referencing previous papers for tool development in the context of clinical assessment, and four listing items without specifying the development procedures). There was little or no evidence supporting test response process (one study reporting rater training), relationship to other variables (two comparing scores in subjects with different clinical experience), and consequences (no studies). Two tools were identified to have evidence for video assessment, specific to NF. CONCLUSION: There is limited evidence supporting the validity of assessment tools for laparoscopic foregut surgery. This precludes their use for summative video-based assessment to verify competency. Further research is needed to develop an assessment tool designed for this purpose.

A scoping review of assessment tools for laparoscopic suturing.

BACKGROUND: A needs assessment identified a gap in teaching and assessment of laparoscopic suturing (LS) skills. The purpose of this review is to identify assessment tools that were used to assess LS skills, to evaluate validity evidence available, and to provide guidance for selecting the right assessment tool for specific assessment conditions. METHODS: Bibliographic databases were searched till April 2017. Full-text articles were included if they reported on assessment tools used in the operating room/simulation to (1) assess procedures that require LS or (2) specifically assess LS skills. RESULTS: Forty-two tools were identified, of which 26 were used for assessing LS skills specifically and 26 for procedures that require LS. Tools had the most evidence in internal structure and relationship to other variables, and least in consequences. CONCLUSION: Through identification and evaluation of assessment tools, the results of this review could be used as a guideline when implementing assessment tools into training programs.

Trends in the Fundamentals of Laparoscopic Surgery® (FLS) certification exam over the past 9 years.

BACKGROUND: The Fundamentals of Laparoscopic Surgery® (FLS) certification exam assesses both cognitive and manual skills, and has been administered for over a decade. The purpose of this study is to report results over the past 9 years of testing in order to identify trends over time and evaluate the need to update scoring practices. This is a quality initiative of the SAGES FLS committee. METHODS: A representative sample of FLS exam data from 2008 to 2016 was analyzed. The de-identified data included demographics and scores for the cognitive and manual tests. Standard descriptive statistics were used to compare trends over the years, training levels, and to assess the pass/fail rate. RESULTS: A total of 7232 FLS tests were analyzed [64% male, 6.4% junior (postgraduate year-PGY1-2), 84% senior (PGY3-5), 2.8% fellows (PGY6), and 6.7% attending surgeons (PGY7)]. Specialties included 93% general surgery (GS), 6.2% gynecology, and 0.9% urology. The Pearson correlation between cognitive and manual scores was 0.09. For the cognitive exam, there was an increase in scores over the years, and the most junior residents scored the lowest. For the manual skills, there were marginal differences in scores over the years, and junior residents scored the highest. The odds ratio of PGY3+ passing was 1.8 (CI 1.2-2.8) times higher than that of a PGY1-2. The internal consistency between tasks on the manual skills exam was 0.73. If any one of the tasks was removed, the Cronbach's alpha dropped to between 0.65 and 0.71, depending on the task being removed. CONCLUSION: The cognitive and manual components of FLS test different aspects of laparoscopy and demonstrate evidence for reliability and validity. More experienced trainees have a higher likelihood of passing the exam and tend to perform better on the cognitive skills. Each component of the manual skills contributes to the exam and should continue to be part of the test.

Development of a Model for the Acquisition and Assessment of Advanced Laparoscopic Suturing Skills Using an Automated Device.

BACKGROUND: Needs assessment identified a gap regarding laparoscopic suturing skills targeted in simulation. This study collected validity evidence for an advanced laparoscopic suturing task using an Endo StitchTM device. METHODS: Experienced (ES) and novice surgeons (NS) performed continuous suturing after watching an instructional video. Scores were based on time and accuracy, and Global Operative Assessment of Laparoscopic Surgery. Data are shown as medians [25th-75th percentiles] (ES vs NS). Interrater reliability was calculated using intraclass correlation coefficients (confidence interval). RESULTS: Seventeen participants were enrolled. Experienced surgeons had significantly greater task (980 [964-999] vs 666 [391-711], P = .0035) and Global Operative Assessment of Laparoscopic Surgery scores (25 [24-25] vs 14 [12-17], P = .0029). Interrater reliability for time and accuracy were 1.0 and 0.9 (0.74-0.96), respectively. All experienced surgeons agreed that the task was relevant to practice. CONCLUSION: This study provides validity evidence for the task as a measure of laparoscopic suturing skill using an automated suturing device. It could help trainees acquire the skills they need to better prepare for clinical learning.