Modeling Technical Skills Learning Curves of Incoming Surgical Trainees.

OBJECTIVE: Not all trainees reach technical competency even after completing surgical training. While assessment of technical skill is not part of the residency interview process, identifying under-performers early on may help identify opportunities for individualized, targeted training. The objectives of this study were to (1) create predictive learning curve (LC) models for each of 3 basic laparoscopic tasks to identify performers versus underperformers and (2) evaluate the use of LCs to identify underperformers during selection into surgical training. DESIGN: Predictive LC models were created for laparoscopic pattern cutting (PC), peg transfer (PT) and intra-corporeal knots (IC) over 40 repetitions by 65 novice trainees in 2014. Trainees were categorized as performers and underperformers. Receiver operator characteristic analysis determined the minimum number of repetitions required to predict individual LCs, which were then used to determine the proportion of underperformers. SETTING: Technical performance was assessed onsite at the Canadian Residence Matching Service (CaRMS) interviews, after interview completion (January 2015). PARTICIPANTS: Applicants to general surgery (GS) and gynecology (OBGYN) participated in a skills assessment during. RESULTS: The PC, PT and IC tasks required a minimum of 8, 10, and 5 repetitions respectively, to predict overall performance. Predictive values for each task had excellent sensitivity and specificity: 1.00, 1.00 (PC); 1.00, 1.00 (PT); and 0.94, 1.00 (IC). Eighty applicants completed 8 PC repetitions; 16% were identified as underperformers. CONCLUSIONS: Individual LCs for three different laparoscopic tasks can be predicted with excellent sensitivity and specificity based on 10 repetitions or less. This information can be used to identify trainees who may have difficulty with laparoscopic technical skills early on.

Spontaneous Intestinal Perforation in Pregnancy from a Pre-Existing Postoperative Adhesion: A Case Report.

BACKGROUND: Spontaneous intestinal perforation is rare in pregnancy. Previously described cases have been associated with endometriosis, Crohn's disease, and intestinal tuberculosis. CASE: We describe a case of spontaneous intestinal perforation in pregnancy from a postoperative adhesion. The patient presented with multiple episodes of abdominal pain and vomiting starting at 255 weeks. The diagnosis was made at 28 weeks when she presented with severe pain and abnormal fetal heart rate requiring emergency cesarean section with bowel resection. CONCLUSION: This case demonstrates that adhesions between the bowel and uterus from prior surgery may lead to spontaneous intestinal perforation as the uterus enlarges during pregnancy. As this diagnosis can be difficult because of imaging limitations and physiologic changes of pregnancy, it should be considered in cases of unremitting abdominal pain and vomiting.

Delivery recommendations for pregnant females with risk factors for rhegmatogenous retinal detachment.

OBJECTIVE: High-risk pathologies for rhegmatogenous retinal detachment (RRD) in otherwise healthy pregnant females are not contraindications for spontaneous vaginal delivery. However, 74% of European obstetrician-gynecologist (OBGYN) respondents in 2008 recommended operative delivery for females at risk for RRD. This discrepancy is likely due to an older study suggesting a causal relation between Valsalva-like manoeuvres and RRD. The purpose of this study is to determine current delivery recommendations for healthy pregnant females with high-risk pathologies for RRD among Canadian ophthalmologists and OBGYNs. METHODS: Anonymous prospective cross-sectional survey sent via electronic link in 2013. χ(2) test of proportions was used to compare delivery recommendations between the 2 specialties. Multinomial logistic regression was used to identify predictors for recommendations. RESULTS: A total of 356 participants responded including 92 ophthalmologists and 27 trainees, and 185 OBGYNs and 52 trainees. For healthy pregnant females with previously treated retinal hole/tear or treated RRD, significantly more OBGYNs recommended cesarean section and significantly more ophthalmologists recommended spontaneous vaginal delivery. Length of practice and type of practice setting were significant predictors among obstetricians in their delivery recommendations. CONCLUSIONS: This study is the first to include obstetricians, ophthalmologists, and their trainees in a survey of the recommended mode of delivery for pregnant females with risk factors of RRD. Our results suggest that obstetricians concerned about potential RRD in pregnant patients may be unnecessarily recommending operative management. Educational sessions on the risk for RRD with spontaneous vaginal delivery may reconcile the current differences in recommendations between ophthalmologists and obstetricians.