Implementing new surgical technology: a national perspective on case volume requirement for proficiency in transanal total mesorectal excision

Background: Early data suggest that transanal total mesorectal excision (TaTME) is a safe alternative to the abdominal approach for rectal cancer. This study aims to understand the approach to the management of rectal cancer in Canada and to ascertain perspectives on introducing TaTME. Methods: Surgeons were invited to complete a survey that asked about their management practices relating to rectal cancer and their opinions regarding TaTME. Results: Ninety-four surgeons completed the survey (38% response rate). The number of rectal cancer cases handled annually by surgeons varied widely (1­80 cases, median 15 cases). Twenty-seven percent of respondents performed TaTME at the time of the survey, and 43% of those who did not said they planned on learning the technique. Surgeons who performed TaTME felt that a higher annual volume of rectal cancer cases was required to maintain proficiency than did non-TaTME surgeons (median 20 cases [interquartile range (IQR) 15­25 cases] v. 15 cases [IQR 10­20 cases]). Surgeons who performed TaTME also felt that a higher annual volume of TaTME cases was required to maintain proficiency (median 12 cases [IQR 10­19 cases] v. 9 cases [IQR 5­10 cases]). Conclusion: These findings help define the current practice environment for rectal cancer surgeons in Canada and highlight the complex issues associated with learning TaTME.

Contexte: Selon des données préliminaires, l'exérèse totale du mésorectum par voie transanale (ou TaTME, pour transanal total mesorectal excision) est une solution de rechange sécuritaire à l'approche abdominale pour le cancer du rectum. Cette étude vise à faire le point sur le traitement du cancer rectal au Canada et à mesurer l'intérêt à l'endroit de la technique TaTME. Méthodes: Des chirurgiens ont été invités à répondre à un sondage sur leur façon de prendre en charge le cancer rectal et sur leur opinion au sujet de la TaTME. Résultats: Quatre-vingt-quatorze chirurgiens ont répondu au sondage (taux deréponse 38 %). Le nombre de cancer rectaux traités annuellement par chirurgien variait grandement (de 1 à 80 cas, nombre médian 15 cas). Vingt-sept pour cent des participants appliquaient la TaTME au moment du sondage et 43 % de ceux qui ne l'appliquaient pas disait avoir l'intention de s'y initier. Les chirurgiens qui appliquaient la TaTME se disaient d'avis qu'il fallait un volume annuel plus élevé de cas de cancer rectal pour garder la main comparativement aux chirurgiens qui n'appliquaient pas cette technique (nombre médian de 20 cas [éventail interquartile (ÉIQ) 15­25 cas] c. 15 cas [ÉIQ 10­20 cas]). Les chirurgiens qui appliquaient la TaTME ont aussi estimé qu'il fallait un volume annuel plus élevé de cas de TaTME pour garder la main (nombre médian de 12 cas [ÉIQ 10­19 cas] c. 9 cases (ÉIQ 5­10 cas]). Conclusion: Ces observations permettent de mieux définir les pratiques actuelles des chirurgiens qui soignent le cancer rectal au Canada et mettent en lumière les enjeux complexes inhérents à l'apprentissage de la TaTME.

A framework to build capacity for a reflex-testing program for Lynch syndrome.

PURPOSE: Lynch syndrome (LS) is the most common inherited cause of colorectal cancer. Although testing all colorectal tumors for LS is recommended, the uptake of reflex-testing programs within health systems has been limited. This multipronged study describes the design of a provincial program for reflex testing in Ontario, Canada. METHODS: We recruited key stakeholders to participate in qualitative interviews to explore the barriers and facilitators to the implementation of a reflex-testing program. Data were analyzed in an iterative manner, key themes identified, and a framework for a proposed program developed. RESULTS: Twenty-six key informants participated in our interviews, and several themes were identified. These included providing education for stakeholders (patients, primary care providers, surgeons); challenges with sustaining various resources (laboratory costs, increased workload for pathologists); ensuring consistency of reporting test results; and developing a plan to measure program success. Using these themes, a framework for the reflex-testing program was developed. At a subsequent stakeholder meeting, the framework was refined, and recommendations were identified. CONCLUSIONS: This study identifies factors to ensure the effective implementation of a population-level program for reflex LS testing. The final product is a prototype that can be utilized in other jurisdictions, taking into account local environmental considerations.

Learning by Example: An International Perspective on Reflex-Testing for Lynch Syndrome.

BACKGROUND: Lynch syndrome (LS), an autosomal dominant cancer syndrome, is the most common cause of hereditary colon cancer. Currently, however, less than 5% of patients with LS have been identified. Reflex-testing programs (in which tumors of patients with colorectal cancer are routinely evaluated for LS) have been proposed for better identification of affected individuals, yet the uptake of these programs within health care systems is limited. This study explored the structure, implementation challenges, and future directions of existing international population-based reflex LS testing programs. METHODS: The study identified existing reflex-testing LS programs through the current literature and through a qualitative sampling approach. Key informants from each program were interviewed. Qualitative data were analyzed using a grounded theory analytic technique approach. RESULTS: The interviews were completed by 26 informants across seven identified programs. Three key themes were identified: (1) tension between a program imposed on stakeholders (a top-down approach) versus initiation of the program at the stakeholder level (bottom-up approach), (2) identification of pathologists as drivers of program success, and (3) strategies to optimize possible LS patients liaising with genetic counselors. Barriers to successful implementation included lack of stakeholder engagement and concerns regarding cost. Facilitators included strong administration to coordinate patient tracking and flexibility during the implementation process. CONCLUSIONS: Existing reflex-testing LS programs have varying structures, standards, and protocols. Program design can have a direct effect on the uptake of genetic testing. These are important considerations in the large-scale planning of LS reflex-testing programs within health systems.

Laparoscopic translevator approach to abdominoperineal resection for rectal adenocarcinoma: feasibility and short-term oncologic outcomes.

BACKGROUND: The extra-levator approach to abdominal perineal resection (APR) was developed in order to reduce the rates of positive circumferential resection margin. This approach, however, is associated with significant morbidity. We postulate that a less radical resection of the levators done laparoscopically could significantly decrease the rate of perineal complications while ensuring an oncologically adequate specimen. To date, to our knowledge, there are no reports in the literature describing a laparoscopic translevator approach for APR. The purpose of this study is to describe our initial experience with this approach and assess our short-term oncologic and clinical outcomes. METHODS: This is a retrospective study of patients who underwent laparoscopic APR with intra-abdominal levator transection for rectal cancer from 2012 to 2014 at a single tertiary care institution. Main outcome measures include: perineal flap rates, post-operative complications, length of stay, distance from tumour to circumferential resection margin, R0 status, and disease recurrence. Data are presented as median (interquartile range) unless otherwise noted. RESULTS: Seventeen cases were identified. Patient age was 61 (range 34-75), and 59 % were male. Pre-operative distance of the tumour from the anal verge was 2.6 cm (0.4-3.9). Post-operative length of stay was 4 (4-6) days. One patient required a perineal flap for reconstruction. Four patients (22 %) had perineal complications (three wound infections and one hernia). No patients reported sexual dysfunction, and one (5 %) developed urinary retention. Five (29 %) patients had a complete pathological response. The circumferential resection margin was 1.5 (0.8-2.5) cm, with no positive margins reported. The number of retrieved lymph nodes was 12 (range 2-30). Follow-up was 9.7 months (range 20 days-23 months), during which one patient developed recurrent disease. CONCLUSIONS: This study describes a novel surgical approach to APR that has the potential to both decrease perineal complications and provide excellent oncologic results.

Individualized deliberate practice on a virtual reality simulator improves technical performance of surgical novices in the operating room: a randomized controlled trial.

OBJECTIVE: The purpose of this study was to investigate whether individualized deliberate practice on a virtual reality (VR) simulator results in improved technical performance in the operating room. BACKGROUND: Training on VR simulators has been shown to improve technical performance in the operating room (OR). Currently described VR curricula consist of trainees practicing the same tasks until expert proficiency is reached. It has yet to be investigated whether the individualized deliberate practice, where curricula tasks vary depending on prior levels of technical proficiency, would translate into the OR. METHODS: This single-blinded prospective trial randomized 16 novice surgical residents to a deliberate practice (DP) group and a conventional residency training group. Both groups performed a laparoscopic cholecystectomy in the OR that was video-recorded. Technical performance of DP group residents in the OR was assessed using 3 validated assessment tools. A score of less than 60% on any component of the assessment tool resulted in the trainee practicing a specific task on the VR simulator. The DP group practiced on the simulator as per their individualized schedule. Both groups then performed another laparoscopic cholecystectomy. A blinded expert assessed the OR recordings using a validated global rating scale. RESULTS: Although both groups had similar technical abilities preintervention [DP: median score, 13.5 (9.3-15.0); control: median score, 14.5 (9.3-17.8); P = 0.45], the DP residents had a superior technical performance postintervention [DP: median score, 17.0 (15.3-18.5); control: median score, 12.5 (7.5-14.0); P = 0.03]. Of 8 DP residents, 6 practiced 5 basic VR tasks (median 1 trial to pass), and 7 of 8 practiced 2 advanced tasks (median 4 trials to pass). CONCLUSIONS: A curriculum of deliberate individualized practice on a VR simulator improves technical performance in the OR. This has implications to greatly improve the feasibility of implementing simulation-based curricula in residency training programs, rather then having them being limited to research protocols.

Validation of a structured training and assessment curriculum for technical skill acquisition in minimally invasive surgery: a randomized controlled trial.

OBJECTIVE: : To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure. BACKGROUND: : Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated. METHODS: : This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills. RESULTS: : Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027). CONCLUSIONS: : Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.).

Development and validation of a comprehensive curriculum to teach an advanced minimally invasive procedure: a randomized controlled trial.

OBJECTIVE: To develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. BACKGROUND: Simulators have been shown to be viable systems for teaching technical skills outside the operating room; however, integration of simulation training into comprehensive curricula remains a major challenge in modern surgical education. Currently, no curricula have been described or validated for advanced laparoscopic procedures. METHODS: This prospective, single-blinded randomized controlled trial allocated 25 surgical residents to receive either conventional residency training or a comprehensive training curriculum for laparoscopic colorectal surgery. The curriculum consisted of proficiency-based psychomotor training on a virtual reality simulator, cognitive training, and participation in a cadaver lab. The primary outcome measure in this study was surgical performance in the operating room. All participants performed a laparoscopic right colectomy, which was video recorded and assessed using 2 previously validated assessment tools. Secondary outcome measures were knowledge relating to the execution of the procedure, assessed with a multiple-choice test, and technical performance on the simulator. RESULTS: Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents (global score 16.0 [14.5-18.0] versus 8.0 [6.0-14.5], P = 0.030; number of operative steps performed 16.0 [12.5-17.5] versus 8.0 [6.0-14.5], P = 0.021; procedure-specific score 71.1 [54.4-81.6] versus 51.1 [36.7-74.4], P = 0.122). Curricular-trained residents scored higher on the multiple-choice test (10 [9-11] versus 7.5 [5.3-7.5], P = 0.047), and outperformed conventionally trained residents in 7 of 8 tasks on the simulator. CONCLUSIONS: Participation in a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery results in improved technical knowledge and improved performance in the operating room compared with conventional residency training. Reg. ID#NCT 01371136.

A comparison of 2 ex vivo training curricula for advanced laparoscopic skills: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness and cost of 2 ex vivo training curricula for laparoscopic suturing. BACKGROUND: Although simulators have been developed to teach laparoscopic suturing, a barrier to their wide implementation in training programs is a lack of knowledge regarding their relative training benefit and their associated cost. METHOD: This prospective single-blinded randomized trial allocated 24 surgical residents to train to proficiency using either a virtual reality (VR) simulator or box trainer. All residents then placed intracorporeal laparoscopic stitches during a Nissen fundoplication on a patient. The operating room (OR) cases were video-recorded and technical proficiency was assessed using 2 validated tools. OR performance of both groups was compared to that of conventionally trained residents and to fellowship-trained surgeons. A cost analysis of box training, VR training, and conventional residency training across Canadian surgical programs was performed. RESULTS: After ex vivo training, no significant differences in laparoscopic suturing in the OR were found between the 2 groups with respect to time (P = 0.74)-global rating score (P = 0.65) or checklist score (P = 0.97). It took conventionally trained residents 6 practice attempts in the OR to achieve the technical proficiency of the ex vivo trained groups (P = 0.83). VR training was more efficient than box training (transfer effectiveness ratio of 2.31 vs 1.13). The annual cost of training 5 residents on the FLS trainer box was $11,975.00, on the VR simulator was $77,500.00, and conventional residency training was $17,380.00. Over 5 years, box training was the most cost-effective option for all programs, and VR training was more cost-effective for programs with more 10 residents. CONCLUSIONS: Training on either a VR simulator or on a box trainer significantly decreased the learning curve necessary to learn laparoscopic suturing. VR training, however, is the more efficient training modality, whereas box training the more cost-effective option.

A prospective study demonstrating the reliability and validity of two procedure-specific evaluation tools to assess operative competence in laparoscopic colorectal surgery.

BACKGROUND: Laparoscopic colorectal surgery is considered an advanced minimally invasive procedure with a long, variable learning curve. Developing an evaluation tool is essential to ensure that individuals reach a certain level of competence prior to performing this procedure independently. To achieve standardization and wide implementation, an assessment tool must be reflective of practice across many institutions. STUDY DESIGN: The purpose of this study is to validate two procedure-specific evaluation tools for laparoscopic colorectal surgery that were developed using innovative consensus methodology. Two procedure-specific rating scales for laparoscopic right and sigmoid colectomy were created using the Delphi method. Nine novice and nine expert laparoscopic sigmoid colectomy videos were prospectively collected, and nine novice and ten expert laparoscopic right colectomy videos were recorded. The experts rated the videos using the procedure-specific technical skills evaluation tool for either laparoscopic right colectomy or laparoscopic sigmoid colectomy. RESULTS: There were statistically significant differences between the expert and novice scores on the laparoscopic right colectomy evaluation tool: the median score of novices was 63.8% and the expert score was 73.1% (p = 0.02). Similarly, there was a significant difference between the median novice score on the sigmoid tool (58.6%) compared with the median expert score (70.7%) (p = 0.003). Cronbach's alpha was 0.82 for the right colectomy evaluation tool and 0.79 for the sigmoid rating scale. CONCLUSIONS: The procedure-specific evaluation tools for laparoscopic right and sigmoid colectomy demonstrate strong reliability and construct validity, and have the potential to be used for technical skills assessment and feedback.

Creating a Practical Transformational Change Management Model for Novel Artificial Intelligence-Enabled Technology Implementation in the Operating Room.

Objective: To identify change management (CM) strategies for implementing novel artificial intelligence and similar novel technologies in operating rooms and create a new CM model for future trials and applications inspired by the abovementioned strategies and established models. Methods: Key phases of technology implementation were defined, and strategies for transformational CM were created and applied in a recent CM experience at our institution between October 15, 2020 and October 15, 2021. We appraised existing CM models and propose the newly created model. Results: The key phases of the technology implementation were as follows: (1) team assembly; (2) committee approvals; (3) CM; and (4) system installation and go-live. Key strategies were (1) assemble team with necessary expertise; (2) anticipate potential institutional cultural and regulatory hurdles; (3) add agility to project planning and execution; (4) accommodate institutional culture and regulations; (5) early clinical partner buy-in and stakeholder engagement; and (6) consistent communication, all of which contributed to the new CM model creation. Conclusion: Key CM strategies and a new CM model addressing the unique needs and characteristics of operating room novel technology implementation were identified and created. The new model may be customized and tested for individual institution and project's needs and characteristics.

Ex vivo technical skills training transfers to the operating room and enhances cognitive learning: a randomized controlled trial.

BACKGROUND: Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated. METHODS: We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script. RESULTS: The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03). CONCLUSIONS: Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.

Helping the Surgeon Recover: Peer-to-Peer Coaching after Bile Duct Injury.

BACKGROUND: Bile duct injury sustained during laparoscopic cholecystectomy is associated with high morbidity and mortality, and can be a devastating complication for a general surgeon. We introduce a novel, individualized surgical coaching program for surgeons who recently injured a bile duct in laparoscopic cholecystectomy. We aim to explore the perception of coaching among these surgeons and to assess surgeons' experiences in the coaching program. STUDY DESIGN: Six general surgeons who injured a bile duct at an emergency laparoscopic cholecystectomy participated in a 1-on-1 coaching session with a hepatopancreatobiliary surgeon. The session focused on debriefing the index case with video feedback, and discussion of strategies for safe laparoscopic cholecystectomy. The pilot program ran from March to November 2020. Exit interviews were then conducted. Themes covering perception of surgical training, perception of complications, and experience in the coaching program were explored. RESULTS: Surgeons were generally accepting of the coaching program, especially when the goals aligned with their self-identified areas of development. One-on-1 sessions with a local expert in the area, and the use of video feedback created a unique and interactive coaching opportunity. Peer coaching was identified as a valuable resource in helping surgeons regain confidence and maintain well-being after a bile duct injury. Maintaining a collegial, nonjudgmental relationship is critical in establishing positive coaching experiences. CONCLUSIONS: An individualized surgical coaching program creates a unique opportunity for professional development and may help promote safe laparoscopic cholecystectomy.

Resident perceptions of advanced laparoscopic skills training.

BACKGROUND: The purpose of this study was to explore resident perceptions regarding four current models for teaching laparoscopic suturing and to assess the current quality of training in advanced minimally invasive surgical techniques at an academic teaching center. METHODS: This study included 14 senior general surgery residents (PGY 3-5) participating in a workshop in advanced laparoscopy. Four training tools were used in the course curriculum: the Fundamentals of Laparoscopic Surgery (FLS) black box suturing model, a synthetic Nissen fundoplication model, a virtual reality (VR) simulator suturing task, and a porcine jejuno-jejunostomy model. After the workshop, residents were asked to complete a questionnaire relating to their experience with laparoscopic surgery, and their opinions regarding the four training models. Model rank was analyzed with one-way ANOVA, and χ(2) analysis with Fisher's exact test was used to analyze model effectiveness. RESULTS: The majority of residents had strong experience in basic laparoscopic cases such as cholecystectomy and appendectomy; however, few participants had experience in advanced cases. As a group, the residents ranked the porcine model first (average 1.6, median 1), followed by the synthetic Nissen model (average 2.0, median 2), the FLS model (average 2.5, median 3), and the VR trainer (average 3.2, median 4). Finally, each resident was asked to rate the four models individually with respect to their educational value. Scores were on a Likert scale from 1 to 5. Nine of 11 (81.8%) residents rated the animal model as "extremely helpful" while only 3 of 14 (21.4%) participants rated the VR model as "extremely helpful" (p = 0.048). CONCLUSIONS: This study demonstrates that operative experience in advanced laparoscopy for senior residents is suboptimal. Residents learning this skill in a simulated environment prefer animal or video-trainers as teaching models rather than virtual reality. This has implications when designing a curriculum for advanced endoscopy.

Assessing the effect of a hands-on oncoplastic surgery training course: A survey of Canadian surgeons.

BACKGROUND: The adoption of oncoplastic surgery in North America is poor despite evidence supporting the benefits. Surgeons take courses to acquire oncoplastic techniques, however, the effect of these courses is unknown. This study aimed to assess the impact of a hands-on oncoplastic course on surgeons' comfort with oncoplastic techniques and rate of adoption of these techniques in their practice. MATERIAL AND METHODS: An online 10-question survey was developed and distributed to surgeons who had participated in a hands-on oncoplastic course offered in Ontario, Canada. Categorical data were reported using frequencies and percentages. RESULTS: A total of 105 surveys were sent out of which 69 attending surgeons responded (response rate: 65.7%). All respondents stated cosmesis was of the utmost importance in breast conserving surgery. The most common oncoplastic techniques they currently use included glandular re-approximation (98.4%), undermining of skin (93.6%), undermining of the nipple areolar complex (63.4%), and de-epithelialization and repositioning of the nipple areola complex (49.2%). Only 26% of respondnets stated they used more advanced techniques such as mammoplasty. Sixty percent of surgeons reported they used oncoplastic techniques in at least half of their cases. Ninety-two percent of respondents stated that the hands-on course increased the amount of oncoplastic techniques in their practice. At least 70% of respondents stated they would do another hands-on course. The main factor that facilitated the uptake of oncoplastic techniques was a better understanding of surgical techniques and planning. CONCLUSION: A hands-on oncoplastic course helps surgeons adopt oncoplastic surgery techniques into their clinical practice. This teaching model allows surgeons to become comfortable with a variety of techniques. This study supports the relevance of a hands-on oncoplastic course to enhance the availability of safe oncoplastic surgery for breast cancer patients.

Peer coaching to teach faculty surgeons an advanced laparoscopic skill: A randomized controlled trial.

BACKGROUND: Preliminary evidence suggests that coaching is an effective adjunct in resident training. The learning needs of faculty, however, are different from those of trainees. Assessing the effectiveness of peer coaching at improving the technical proficiency of practicing surgeons is an area that remains largely unexplored. The purpose of this study was to assess the efficacy of a peer coaching program that teaches laparoscopic suturing to faculty surgeons. METHODS: Surgeons inexperienced in laparoscopic suturing were randomized to either conventional training or peer coaching. Both groups performed a pretest on a box trainer. The conventional training group then received a web link to a tutorial for teaching laparoscopic suturing and a box trainer for independent practice. In addition to the web link and the box trainer, the peer coaching group received 2 half hour peer coaching sessions. Both groups then performed a stitch on the box trainer that was video recorded. The primary outcome measure was technical performance, which was assessed by a global rating scale. RESULTS: Eighteen faculty were randomized (conventional training n = 9; peer coaching n = 9). Initially, there was no difference in technical skills between the groups (conventional training median score 10 [interquartile range 8.5-15]; peer coaching 13 [10.5-14]; P = .64). After the intervention, the peer coaching group had improved technical performance (conventional training 11 [8.5-12.5]; peer coaching 18 [17-19]; P < .01). Comparing the pre- and postintervention scores within both groups, there was an improvement in technical proficiency in the peer coaching group, yet none in the conventional training group (before conventional training 10 [8.5-15], after conventional training 11 [8.5-12.5]; P = .56; before peer coaching 13 [10.5-14], after peer coaching 18 [17-19]; P < .01). CONCLUSION: This trial demonstrates that a structured peer coaching program can facilitate faculty surgeons learning a novel procedure.

Designing a proficiency-based, content validated virtual reality curriculum for laparoscopic colorectal surgery: a Delphi approach.

BACKGROUND: Although task training on virtual reality (VR) simulators has been shown to transfer to the operating room, to date no VR curricula have been described for advanced laparoscopic procedures. The purpose of this study was to develop a proficiency-based VR technical skills curriculum for laparoscopic colorectal surgery. METHODS: The Delphi method was used to determine expert consensus on which VR tasks (on the LapSim simulator) are relevant to teaching laparoscopic colorectal surgery. To accomplish this task, 19 international experts rated all the LapSim tasks on a Likert scale (1-5) with respect to the degree to which they thought that a particular task should be included in a final technical skills curriculum. Results of the survey were sent back to participants until consensus (Cronbach's α >0.8) was reached. A cross-sectional design was utilized to define the benchmark scores for the identified tasks. Nine expert surgeons completed all identified tasks on the "easy," "medium," and "hard" settings of the simulator. RESULTS: In the first round of the survey, Cronbach's α was 0.715; after the second round, consensus was reached at 0.865. Consensus was reached for 7 basic tasks and 1 advanced suturing task. Median expert time and economy of movement scores were defined as benchmarks for all curricular tasks. CONCLUSION: This study used Delphi consensus methodology to create a curriculum for an advanced laparoscopic procedure that is reflective of current clinical practice on an international level and conforms to current educational standards of proficiency-based training.

Comprehensive training curricula for minimally invasive surgery.

BACKGROUND: The unique skill set required for minimally invasive surgery has in part contributed to a certain portion of surgical residency training transitioning from the operating room to the surgical skills laboratory. Simulation lends itself well as a method to shorten the learning curve for minimally invasive surgery by allowing trainees to practice the unique motor skills required for this type of surgery in a safe, structured environment. Although a significant amount of important work has been done to validate simulators as viable systems for teaching technical skills outside the operating room, the next step is to integrate simulation training into a comprehensive curriculum. OBJECTIVES: This narrative review aims to synthesize the evidence and educational theories underlining curricula development for technical skills both in a broad context and specifically as it pertains to minimally invasive surgery. FINDINGS: The review highlights the critical aspects of simulation training, such as the effective provision of feedback, deliberate practice, training to proficiency, the opportunity to practice at varying levels of difficulty, and the inclusion of both cognitive teaching and hands-on training. In addition, frameworks for integrating simulation training into a comprehensive curriculum are described. Finally, existing curricula on both laparoscopic box trainers and virtual reality simulators are critically evaluated.