Training and assessment for colorectal surgery and appendicectomy- a systematic review.

AIM: There is currently an increased focus on competency-based training, in which training and assessment play a crucial role. The aim of this systematic review is to create an overview of hands-on training methods and assessment tools for appendicectomy and colon and rectal surgery procedures using either an open, laparoscopic or robot-assisted approach. METHOD: A systematic review of Medline, Embase, Cochrane and Scopus databases was conducted following the PRISMA guidelines. We conducted the last search on 9 March 2023. All published papers describing hands-on training, evaluation of performance data and development of assessment tools were eligible. The quality of studies and the validity evidence of assessment tools are reported. RESULTS: Fifty-one studies were identified. Laparoscopic assessment tools are abundant, but the literature still lacks good-quality assessment tools for open appendicectomy, robotic colectomy and open rectal surgery. Overall, there is a lack of discussion regarding the establishment of pass/fail standards and the consequences of assessment. Virtual reality simulation is used more for appendicectomy than colorectal procedures. Only a few of the studies investigating training were of acceptable quality. There is a need for high-quality studies in open and robotic-assisted colon surgery and all approaches to rectal surgery. CONCLUSION: This review provides an overview of current training methods and assessment tools and identifies where more research is needed based on the quality of the studies and the current validity evidence.

Procedure-based assessment implementation in colorectal surgery: a scoping review.

BACKGROUND: Competency-based training (CBT) programs use procedure-based assessments (PBAs) to evaluate trainees' abilities to perform specific procedures in clinical settings, similar to Entrustable Professional Activities (EPAs). PBAs help determine trainees' readiness for advanced training levels. However, there is limited evidence on implementing colorectal-specific PBAs in surgical training schemes. This review aims to identify observed and perceived challenges to implementing PBAs in workplace settings. METHODS: A scoping review following the Joanna Briggs Institute Protocol for Scoping Reviews (JBI-ScR) was conducted. Eligible studies provided evidence on the implementation, feasibility, and challenges of PBAs in colorectal surgery, including various study designs from retrospective to prospective. RESULTS: Of the 80 screened studies, 75 were excluded based on exclusion criteria. Most of the included studies were conducted in national training institutions in the United Kingdom, assessing 778 colorectal procedures with specific PBAs. The main facilitators of implementing PBAs were structured assessments, focused assessors' training, and electronic forms usage. CONCLUSION: This review offers insight into the practicality and feasibility of implementing PBAs in colorectal surgery. Identified challenges include the need for adequate assessor training and the time-consuming nature of the assessment. These findings could improve PBA implementation in colorectal surgery and enhance surgical education quality. However, the limited number of studies and existing literature heterogeneity call for more research to identify other gaps.

Evaluation of Factors Associated With Successful Matriculation to Colon and Rectal Surgery Fellowship.

BACKGROUND: As an increasing number of general surgery residents apply for fellowship positions, it is important to identify factors associated with successful matriculation. For applicants to colon and rectal surgery, there are currently no objective data available to distinguish which applicant attributes lead to successful matriculation. OBJECTIVE: The purpose of this study was to identify objective factors that differentiate colon and rectal surgery fellowship applicants who successfully matriculate with those who apply but do not matriculate. DESIGN: This was a retrospective analysis of colon and rectal surgery applicant characteristics. SETTINGS: Deidentified applicant data provided by the Association of American Medical Colleges from 2015 to 2017 were included. MAIN OUTCOME MEASURES: Applicant demographics, medical school and residency factors, number of program applications, number of publications, and journal impact factors were analyzed to determine associations with successful matriculation. RESULTS: Most applicants (n = 371) and subsequent matriculants (n = 248) were white (61%, 62%), male (65%, 63%), US citizens (80%, 88%) who graduated from US allopathic medical schools (66%, 75%). Statistically significant associations included graduation from US allopathic medical schools (p < 0.0001), US citizenship (p < 0.0001), and number of program applications (p = 0.0004). Other factors analyzed included American Osteopathic Association membership (p = 0.57), university-based residency (p = 0.51), and residency association with a colon and rectal surgery training program (p = 0.89). Number of publications and journal impact factors were not statistically different between cohorts (p = 0.067, p = 0.150). LIMITATIONS: American Board of Surgery In-Training Examination scores, rank list, and subjective characteristics, such as strength of interview and letters of recommendation, were not available using our data source. CONCLUSIONS: Successful matriculation to a colon and rectal surgery fellowship program was found to be associated with US citizenship, graduation from a US allopathic medical school, and greater number of program applications. The remaining objective metrics analyzed were not associated with successful matriculation. Subjective and objective factors that were unable to be measured by this study are likely to play a determining role. See Video Abstract at http://links.lww.com/DCR/B415. EVALUACIN DE FACTORES VINCULADOS EN LA INMATRICULACIN EXITOSA PARA BECAS DE CIRUGA COLORRECTAL: ANTECEDENTES:A medida que un número cada vez mayor de residentes de Cirugía General solicitan una beca, es importante identificar los factores vinculados con una inmatriculación exitosa. Para los candidatos a una beca en Cirugía Colorrectal, hoy en día no existen datos objetivos disponibles para distinguir qué atributos del solicitante conducen a una inmatriculación exitosa.OBJETIVO:Identificar objetivamente los factores que diferencian un candidato a una beca en Cirugía Colorrectal que se inmatricula con éxito de aquel que aplica pero no llega a inmatricularse.DISEÑO:Análisis retrospectivo de las características de los solicitantes de beca para Cirugía Colorrecatl.AJUSTES:Datos de los solicitantes no identificados, proporcionados por la Asociación de Colegios Médicos Estadounidenses de 2015 a 2017.PRINCIPALES MEDIDAS DE RESULTADO:Se analizaron los factores demográficos del solicitante, las facultades de medicina y los factores de la residencia, el número de solicitudes de programas, el número y el factor de impacto de las publicaciones realizadas para determinar la asociación con una inmatriculación exitosa.RESULTADOS:La mayoría de los solicitantes (n = 371) que posteriormente fueron inmatriculados exitosamente (n = 248) eran blancos (61%, 62%, respectivamente), hombres (65%, 63%), ciudadanos estadounidenses (80%, 88%) que se graduaron de Facultades de medicina alopática en los EE. UU. (66%, 75%). Las asociaciones estadísticamente significativas incluyeron la graduación de las escuelas de medicina alopática de los EE. UU. (P <0,0001), la ciudadanía de los EE. UU. (P <0,0001) y el número de solicitudes de programas (p = 0,0004). Otros factores analizados incluyeron: membresía AOA (p = 0,57), la residencia universitaria (p = 0,51) y asociación de la residencia con un programa de formación en Cirugía Colorrectal (p = 0,89). El número de publicaciones y los factores de impacto de las revistas no fueron estadísticamente diferentes entre las cohortes (p = 0,067, p = 0,15, respectivamente).LIMITACIONES:El Score ABSITE, la posición en lista de clasificación y las características subjetivas como el de una buena entrevista y las cartas de recomendación no se encontraban disponibles en la fuente de datos.CONCLUSIONES:Se encontró que la inmatriculación exitosa a un programa de becas de Cirugía Colorreectal estaba asociada con la ciudadanía estadounidense, la graduación en una Facultad de medicina alopática en los EE. UU, y al mayor número de solicitudes de programas. El analisis de las medidas objetivas restantes no se asociaron con una inmatriculación exitosa. Es probable que los factores subjetivos y objetivos que no pudieron ser medidos por este estudio jueguen un papel determinante. Consulte Video Resumen en http://links.lww.com/DCR/B415. (Traducción-Dr Xavier Delgadillo).

Colon and Rectal Surgery Robotic Training Programs: An Evaluation of Gender Disparities.

BACKGROUND: Female surgeons are subjected to implicit bias throughout their careers. The evaluation of gender bias in training is warranted with increasing numbers of female trainees in colon and rectal surgery. OBJECTIVE: This study aimed to evaluate gender bias in colon and rectal surgery training program operative experience. DESIGN: This is a retrospective cohort study. SETTING: The Association of Program Directors for Colon and Rectal Surgery robotic case log database contains operative details (procedure, attending surgeon, case percentage, and operative segments) completed by trainees as console surgeon for 2 academic years (2016-2017, 2017-2018). MAIN OUTCOME MEASURE: The primary outcomes measured are the percentage of trainee console participation and the completion of total mesorectal excision. Resident and attending surgeon gender was recorded retrospectively. The cohort was separated into 4 groups based on resident and attending surgeon gender combination. Case volume, average console participation per case, and completion of total mesorectal excisions were compared for each group by using interaction regression analysis. RESULTS: Fifty-two training programs participated, including 120 trainees and 190 attending surgeons. Forty-five (37.5%) trainees and 36 (18.9%) attending surgeons were women. The average number of cases per trainee was 23.27 per year for women and 28.15 per year for men (p = 0.19). Average console participation was 53.5% for women and 61.7% for men (p < 0.001). Male attending surgeons provided female trainees less console participation than male counterparts (52.1% vs 59.7%, p < 0.001). Female attending surgeons provided the same amount of console participation to female and male trainees (63.3% vs 61.8%, p = 0.62). Male trainees performed significantly more complete total mesorectal excision console cases than female trainees (57.16% vs 42.38%, p < 0.0001). LIMITATIONS: The data are subject to self-reporting bias. CONCLUSIONS: There is gender disparity in robotic operative experience in colon and rectal surgery training programs with less opportunity for console participation and less opportunity to complete total mesorectal excisions for female trainees. This trend should be highlighted and further evaluated to resolve this disparity. See Video Abstract at http://links.lww.com/DCR/B224. PROGRAMAS DE CAPACITACIÓN ROBÓTICA SOBRE CIRUGÍA DE COLON Y RECTO: UNA EVALUACIÓN DE LAS DISPARIDADES DE GÉNERO: Cirujanos mujeres están sujetas a sesgos implícitos a lo largo de sus carreras. La evaluación del sesgo de género en el entrenamiento se amerita por un número cada vez mayor de aprendices femeniles en cirugía de colon y recto.Evaluar el sesgo de género en la experiencia operativa en programas de entrenamiento de cirugía de colon y recto.Estudio de cohorte retrospectivo.La base de datos de registro de casos robóticos de la Asociación de Directores de Programas para Cirugía de Colon y Rectal contiene detalles operativos (procedimiento, cirujano asistente, porcentaje de casos y segmentos operativos) completados por los alumnos como cirujanos de consola durante dos años académicos (2016-17, 2017-18).Porcentaje de participación de la consola de entrenamiento y finalización de la escisión mesorrectal total. Se registraron retrospectivamente el sexo de los médicos residentes y asistentes. La cohorte se separó en cuatro grupos según la combinación de género residente y asistente. El volumen de casos, la participación promedio de la consola por caso y la finalización de las extirpaciones mesorrectales totales se compararon para cada grupo mediante el análisis de regresión de interacción.Participaron 52 programas de capacitación, incluidos 120 aprendices y 190 cirujanos asistentes. Cuarenta y cinco (37.5%) aprendices y 36 (18.9%) cirujanos asistentes eran mujeres. El número promedio de casos por aprendiz fue de 23.27 / año para mujeres y 28.15 / año para hombres (p = 0.19). La participación promedio de la consola fue del 53.5% para las mujeres y del 61.7% para los hombres (p <0.001). Los cirujanos asistentes masculinos proporcionaron a las mujeres aprendices menos participación en la consola en comparación con sus compañeros masculinos (52.1% vs 59.7%, p <0.001). Los cirujanos asistentes femeninos proporcionaron la misma cantidad de participación en la consola a los aprendices femeninos y masculinos (63.3% vs 61.8%, p = 0.62). Los aprendices masculinos realizaron casos de consola TME significativamente más completos que las aprendices femeninas (57.16% vs 42.38%, p <0.0001).Los datos están sujetos a sesgos de autoinforme.Existe una disparidad de género en la experiencia quirúrgica robótica en los programas de entrenamiento de cirugía de colon y recto con menos oportunidades para la participación de la consola y menos oportunidades para completar las extirpaciones mesorrectales totales para las mujeres en formación. Esta tendencia debe destacarse y evaluarse para resolver esta disparidad. Consulte Video Resumen en http://links.lww.com/DCR/B224. (Traducción-Dr. Adrián Ortega).

An assessment of an Australasian pathway for the introduction of transanal total mesorectal excision (taTME).

AIM: To evaluate the use of a pathway for the introduction of transanal total mesorectal excision (taTME) into Australia and New Zealand. METHOD: A pathway for surgeons with an appropriate level of specialist training and baseline skill set was initiated amongst colorectal surgeons; it includes an intensive course, a series of proctored cases and ongoing contribution to audit. Data were collected for patients who had taTME, for benign and malignant conditions, undertaken by the initial adopters of the technique. RESULTS: A total of 133 taTME procedures were performed following the introduction of a training pathway in March 2015. The indication was rectal cancer in 84% of cases. There was one technique-specific visceral injury, which occurred prior to that surgeon completing the pathway. There were no cases of postoperative mortality; morbidity occurred in 27.1%. The distal resection margin was clear in all cases of rectal cancer, and the circumferential resection margin was positive in two cases. An intact or nearly intact total mesorectal excision was obtained in more than 98% of cases. CONCLUSION: This study demonstrates the safe and controlled introduction of a new surgical technique in a defined surgeon population with the use of a pathway for training. The authors recommend a similar pathway to facilitate the introduction of taTME to colorectal surgical practice.

Uptake of Transanal Total Mesorectal Excision in North America: Initial Assessment of a Structured Training Program and the Experience of Delegate Surgeons.

BACKGROUND: Transanal total mesorectal excision is a new approach to curative-intent rectal cancer surgery. Training and surgeon experience with this approach has not been assessed previously in America. OBJECTIVE: The purpose of this study was to characterize a structured training program and to determine the experience of delegate surgeons. DESIGN: Data were assimilated from an anonymous, online survey delivered to attendees on course completion. Data on surgeon performance during hands-on cadaveric dissection were collected prospectively. SETTINGS: This study was conducted at a single tertiary colorectal surgery referral center, and cadaveric hands-on training was conducted at a specialized surgeon education center. MAIN OUTCOME MEASURES: The main outcome measurement was the use of the course and surgeon experience posttraining. RESULTS: During a 12-month period, eight 2-day transanal total mesorectal excision courses were conducted. Eighty-one colorectal surgeons successfully completed the course. During cadaveric dissection, 71% achieved a complete (Quirke 3) specimen; 26% were near complete (Quirke 2), and 3% were incomplete (Quirke 1). A total of 9.1% demonstrated dissection in the incorrect plane, whereas 4.5% created major injury to the rectum or surrounding structures, excluding the prostate. Thirty eight (46.9%) of 81 surgeon delegates responded to an online survey. Of survey respondents, 94.6% believed training should be required before performing transanal total mesorectal excision. Posttraining, 94.3% of surgeon delegates planned to use transanal total mesorectal excision for distal-third rectal cancers, 74.3% for middle-third cancers, and 8.6% for proximal-third cancers. The most significant complication reported was urethral injury; 5 were reported by the subset of survey respondents who had performed this operation postcourse. LIMITATIONS: The study was limited by inherent reporting bias, including observer and recall biases. CONCLUSIONS: Although this structured training program for transanal total mesorectal excision was found to be useful by the majority of respondents, the risk of iatrogenic injury after training remains high, suggesting that this training pedagogy alone is insufficient. See Video Abstract at http://links.lww.com/DCR/A335.

Does Sex Influence Publication Productivity Among Colorectal Surgeons Participating in Fellowship Training Programs?

BACKGROUND: Underrepresentation of highly ranked women in academic surgery is recognized. OBJECTIVE: Our objective was to examine whether sex differences exist in faculty representation, academic rank, and publication productivity among colorectal faculty in fellowship programs. DESIGN: American Society of Colon and Rectal Surgeons fellowship program faculty were identified. Bibliometric data were obtained for each faculty member, including Hirsch index, the Hirsch index divided by research career duration, and number of publications. Linear mixed-effect regression models were constructed to determine the association between the Hirsch index and the Hirsch index divided by research career duration and sex, when controlling for institutional measures. A subset analysis of academic faculty examined the association between academic rank, sex, and Hirsch index and the Hirsch index divided by research career duration. SETTINGS: Colorectal fellowship programs, defined as academic, satellite-academic, and nonacademic, were evaluated. RESULTS: Three hundred fifty-eight faculty members were examined across 55 training programs; 22% (n = 77) were women and 78% (n = 281) were men. Sixty-one percent (n = 220) practiced in an academic setting, 23% (n = 84) in a satellite-academic setting, and 15% (n = 54) in a nonacademic setting. There was no difference in median number of publications between sexes (15 vs 10, p = 0.33); men, however, had longer careers (18 vs 11 years, p < 0.001). When controlling for confounders, there was no difference in the Hirsch index (p = 0.42) or the Hirsch index divided by research career duration (p = 0.73) between sexes. Academic rank was significantly associated with Hirsch index and the Hirsch index divided by research career duration (p < 0.001) after controlling for sex. LIMITATIONS: Our assessment of association between publication productivity and academic rank was only possible in the subset of academic faculty. In addition, this study is limited by its retrospective nature. CONCLUSIONS: We found no difference in median number of publications between men and women. When controlling for possible confounders, sex was not a significant predictor of a faculty member's publication productivity, as measured by the Hirsch index or the Hirsch index divided by research career duration; academic rank, however, was.

The Impact on Endoscopic Resource Utilization After a Targeted Intervention for Cost-Minimization of EGD and Colonoscopy.

OBJECTIVES: The need to define the cost of endoscopic procedures becomes increasingly important in an era of providing low-cost, high-quality care. We examined the impact of informing endoscopists of the cost of accessories and pathology specimens as a cost-minimization strategy. METHODS: We conducted a prospective observational cohort study of therapeutic outpatient esophagogastroduodenoscopy (EGD) and colonoscopy. During the pre-intervention phase (phase 1), the endoscopists were not briefed on the cost of accessories or pathology specimens obtained during the procedure. During a 3-week intervention phase and the post-intervention phase (phase 2) endoscopists were informed of the dollar value of accessories and pathology specimens after the completion of all procedures. In all cases the institutional costs (not charges) were used. The endoscopists were blinded to their observation. RESULTS: A total of 969 EGD, colonoscopy, and EGD+colonoscopy performed by 6 endoscopists were reviewed, 456 procedures in phase 1 and 513 procedures in phase 2. There was no significant difference between phases 1 and 2 in total device and pathology cost in dollars (188.8±151.4 vs. 188.9±151.8, P=0.99), total device cost (36.2±107.9 vs. 39.0±95.96, P=0.67) and total pathology cost (152.6±101.3 vs. 149.9±112.5, P=0.70). There was not a significant difference in total device and pathology cost when examined by specific procedures performed, or for any of the endoscopists between phases 1 and 2. CONCLUSIONS: Making endoscopists more cost conscious by informing them of the costs of each procedure during EGD and colonoscopy does not result in lower procedural costs. Analysis of cost-minimization strategies involving procedures in other health-care settings and procedures using high-cost accessories are warranted.

Robotic Versus Laparoscopic Right Colectomy for Colon Cancer: Analysis of the Initial Simultaneous Learning Curve of a Surgical Fellow.

BACKGROUND: Robotic surgery was introduced to overcome laparoscopic drawbacks. This study aimed to compare the learning curve of robotic-assisted right colectomy (RRC) versus laparoscopic-assisted right colectomy (LRC) for colon cancer with respect to operative times and perioperative outcomes. In addition, the health-related costs associated with both procedures were analyzed and compared. METHODS: Between 2012 and 2015, 30 consecutive patients underwent RRC and 50 patients LRC for colon cancer. All procedures were performed by a surgical fellow novice in minimally invasive colorectal surgery. The operative time and the cumulative sum method were used to evaluate the learning curve of RRC versus LRC. RESULTS: The mean operative times were 200.5 minutes for RRC and 204.1 minutes for LRC (P = .408) and showed a significant decrease over consecutive procedures (P < .0001). The number of cases necessary to identify a drop in the operative time was 16 for RRC and 25 for LRC. RRC procedures were associated with significantly reduced blood loss (P = .012). Two patients (4%) in the LRC group were converted to laparotomy, whereas no conversion was required in the RRC group. Surgery-related costs were significantly more expensive for RRC, but when combined with the hospitalization-related costs, LRC and RRC did not differ (P = .632). CONCLUSIONS: Both robotic and laparoscopic operative times decrease rapidly with practice. However, RRC is associated with a faster learning curve than LRC. The simultaneous development of these two minimally invasive approaches appears to be safe and feasible with acceptable health-related costs.

Implementing and Evaluating a National Certification Technical Skills Examination: The Colorectal Objective Structured Assessment of Technical Skill.

OBJECTIVE: To implement the Colorectal Objective Structured Assessment of Technical skill (COSATS) into American Board of Colon and Rectal Surgery (ABCRS) certification and build evidence of validity for the interpretation of the scores of this high stakes assessment tool. BACKGROUND DATA: Currently, technical skill assessment is not a formal component of board certification. With the technical demands of surgical specialties, documenting competence in technical skill at the time of certification with a valid tool is ideal. METHODS: In September 2014, the COSATS was a mandatory component of ABCRS certification. Seventy candidates took the examination, with their performance evaluated by expert colorectal surgeons using a task-specific checklist, global rating scale, and overall performance scale. Passing scores were set and compared using 2 standard setting methodologies, using a compensatory and conjunctive model. Inter-rater reliability and the reliability of the pass/fail decision were calculated using Cronbach alpha and Subkoviak methodology, respectively. Overall COSATS scores and pass/fail status were compared with results on the ABCRS oral examination. RESULTS: The pass rate ranged from 85.7% to 90%. Inter-rater reliability (0.85) and reliability of the pass/fail decision (0.87 and 0.84) were high. A low positive correlation (r= 0.25) was seen between the COSATS and oral examination. All individuals who failed the COSATS passed the ABCRS oral examination. CONCLUSIONS: COSATS is the first technical skill examination used in national surgical board certification. This study suggests that the current certification process may be failing to identify individuals who have demonstrated technical deficiencies on this standardized assessment tool.

Structured training and competence assessment in colorectal robotic surgery. Results of a consensus experts round table.

BACKGROUND: A structured training is a key element for the learning of techniques with a high level of complexity, such as robotic colorectal surgery. METHODS: This study reports the results of an expert consensus round table held during the 6th Clinical Robotic Surgery Association (CRSA) congress, focusing on recommendations in robotic colorectal surgery. RESULTS: Three sequential steps are proposed for training: a basic module, to learn basic robotic skills and general competencies; an advanced module, to acquire skills to safely perform a colorectal resection, and tutored clinical practice providing procedures of increasing complexity. Each specific skill of the basic module and performance of each surgical step of a colorectal procedure was evaluated and rated from 1 to 3. CONCLUSIONS: Defining requirements to begin robotic colorectal activity, delineation of structured training programs and objectification of the acquired competences are key elements for a safe and efficient learning of robotic colorectal surgery. Copyright © 2016 John Wiley & Sons, Ltd.

What errors make a laparoscopic cancer surgery unsafe? An ad hoc analysis of competency assessment in the National Training Programme for laparoscopic colorectal surgery in England.

BACKGROUND: The National Training Programme for laparoscopic colorectal surgery in England was implemented to ensure training was supervised, structured, safe and effective. Delegates were required to pass a competency assessment (sign-off) before undertaking independent practice. This study described the types of errors identified and associated these errors with competency to progress to independent laparoscopic colorectal practice. METHODS: All sign-off submissions from the start of the process in January 2008 until July 2013 were included. Content analysis was used to categorise errors. Bayes factor (BF) was used to measure the impact of individual error on assessment outcome. A smaller BF indicates that an error has stronger associations with unsuccessful assessments. Bayesian network was employed to graphically represent the reasoning process whereby the chance of successful assessment diminished with the identification of each error. Quality of the error feedback was measured by the area under the ROC curve which linked the predictions from the Bayesian model to the expert verdict. RESULTS: Among 370 assessments analysed, 240 passed and 130 failed. On average, 2.5 different types of error were identified in each assessment. Cases that were more likely to fail had three or more different types of error (χ(2) = 72, p < 0.0001) and demonstrated poorer technical skills (CAT score <2.7, χ(2) = 164, p < 0.0001). Case complexity or right- versus left-sided resection did not have a significant impact. Errors associated with dissection (BF = 0.18), anastomosis (BF = 0.23) and oncological quality (BF = 0.19) were critical determinants of surgical competence, each reducing the odds of pass by at least fourfold. The area under the ROC curve was 0.84. CONCLUSIONS: Errors associated with dissection, anastomosis and oncological quality were critical determinants of surgical competency. The detailed error analysis reported in this study can guide the design of future surgical education and clinical training programmes.

Development and implementation of the Structured Training Trainer Assessment Report (STTAR) in the English National Training Programme for laparoscopic colorectal surgery.

BACKGROUND: There is a lack of educational tools available for surgical teaching critique, particularly for advanced laparoscopic surgery. The aim was to develop and implement a tool that assesses training quality and structures feedback for trainers in the English National Training Programme for laparoscopic colorectal surgery. METHODS: Semi-structured interviews were performed and analysed, and items were extracted. Through the Delphi process, essential items pertaining to desirable trainer characteristics, training structure and feedback were determined. An assessment tool (Structured Training Trainer Assessment Report-STTAR) was developed and tested for feasibility, acceptability and educational impact. RESULTS: Interview transcripts (29 surgical trainers, 10 trainees, four educationalists) were analysed, and item lists created and distributed for consensus opinion (11 trainers and seven trainees). The STTAR consisted of 64 factors, and its web-based version, the mini-STTAR, included 21 factors that were categorised into four groups (training structure, training behaviour, trainer attributes and role modelling) and structured around a training session timeline (beginning, middle and end). The STTAR (six trainers, 48 different assessments) demonstrated good internal consistency (α = 0.88) and inter-rater reliability (ICC = 0.75). The mini-STTAR demonstrated good inter-item reliability (α = 0.79) and intra-observer reliability on comparison of 85 different trainer/trainee combinations (r = 0.701, p = <0.001). Both were found to be feasible and acceptable. The educational report for trainers was found to be useful (4.4 out of 5). CONCLUSIONS: An assessment tool that evaluates training quality was developed and shown to be reliable, acceptable and of educational value. It has been successfully implemented into the English National Training Programme for laparoscopic colorectal surgery.

A multi-modal approach to training in laparoscopic colorectal surgery accelerates proficiency gain.

BACKGROUND: How to efficiently train and transfer skills in laparoscopic colorectal surgery is unclear. Errors are rarely avoidable during learning but may incur patient morbidity. Multi-modality training with a modular operative approach provides proficiency-based structured task-specific training in a sequential manner, fragmenting complex laparoscopic colorectal procedures by difficulty allowing more than one trainee to gain experience irrespective of prior experience. This study assessed multi-modality training and its effect on proficiency gain in laparoscopic colorectal fellows. METHODS: A prospective study of 750 consecutive laparoscopic colon and rectal resection training cases assessing proficiency gain using a modified direct observation of procedural skills (DOPS) (behaviors-assessment) and weighted global modular attainment score (GMAS) (maneuvers-assessment) was carried out. Two mentors delivered training in a standardized format from 2008. Consequential intra-operative errors (requiring a corrective maneuver to permit further progression of the operation) were recorded. Eight Laparoscopic Fellows were assessed in six-month periods over 4 years. Primary outcome was proficiency gain measured by cumulative sum (CUSUM) analysis with boot-strapping comparing weighted GMAS and modified DOPS assessment. Morbidity (Clavien-Dindo classification), and consequential errors were submitted to similar analysis to assess significant variations during the training period. RESULTS: Fellows were trained on over 100 laparoscopic colorectal resections in a six Fellowship month period. Proficiency gain was identifiable in the DOPS and GMAS with 32 (99 % CI 25-37) and 39 (99 % CI 32-44) cases, respectively. Two- versus single-mentor training improved proficiency gain 35 (99 % CI 30-43) versus 55 (99 % CI 50-60). Overall consequential error rate and major morbidity rate (CD III-IV) were stable over time at 25 and 8.7 %, respectively. CONCLUSIONS: Multi-modality training with modular operative training and technique standardization shortens the time to proficiency gain with low morbidity accepting an intra-operative consequential error rate of 25 %.

Clinical validity of consultant technical skills assessment in the English National Training Programme for Laparoscopic Colorectal Surgery.

BACKGROUND: The English National Training Programme for Laparoscopic Colorectal Surgery introduced a validated objective competency assessment tool to accredit surgeons before independent practice. The aim of this study was to determine whether this technical skills assessment predicted clinical outcomes. METHODS: Established consultants, training in laparoscopic colorectal surgery, were asked to submit two operative videos for evaluation by two blinded assessors using the competency assessment tool. A mark of 2·7 or above was considered a pass. Clinical and oncological outcomes were compared above and below this mark, including regression analysis. RESULTS: Eighty-five consultant surgeons submitted 171 videos. Of these, 44 (25·7 per cent) were in the fail group (score less than 2·7). This low scoring group had more postoperative morbidity (25 versus 8·7 per cent; P = 0·005), including surgical complications (18 versus 6·3 per cent; P = 0·020) and fewer lymph nodes harvested (median 13 versus 18; P = 0·004). A score of less than 2·7 was an independent predictor of surgical complication, lymph node yield and distal resection margin clearance. Consultants with higher scores had performed similar numbers of laparoscopic colorectal operations (median 37 versus 40; P = 0·373) but more structured training operations (18 versus 9; P < 0·001). CONCLUSION: An objective technical skills assessment provided a discriminatory tool with which to accredit laparoscopic colorectal surgeons.