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.

Evaluating Educational Outcomes Using Patient Outcomes of New Surgeons Performing Partial Colectomy Compared to Cholecystectomy.

PURPOSE: Despite ongoing efforts to improve surgical education, surgical residents face gaps in their training. However, it is unknown if differences in the training of surgeons are reflected in the patient outcomes of those surgeons once they enter practice. This study aimed to compare the patient outcomes among new surgeons performing partial colectomy-a common procedure for which training is limited-and cholecystectomy-a common procedure for which training is robust. METHOD: The authors retrospectively analyzed all adult Medicare claims data for patients undergoing inpatient partial colectomy and inpatient cholecystectomy between 2007 and 2018. Generalized additive mixed models were used to investigate the associations between surgeon years in practice and risk-adjusted rates of 30-day serious complications and death for patients undergoing partial colectomy and cholecystectomy. RESULTS: A total of 14,449 surgeons at 4,011 hospitals performed 340,114 partial colectomy and 355,923 cholecystectomy inpatient operations during the study period. Patients undergoing a partial colectomy by a surgeon in their 1st vs 15th year of practice had higher rates of serious complications (5.22% [95% CI, 4.85%-5.60%] vs 4.37% [95% CI, 4.22%-4.52%]; P < .01) and death (3.05% [95% CI, 2.92%-3.17%] vs 2.83% [95% CI, 2.75%-2.91%]; P < .01). Patients undergoing a cholecystectomy by a surgeon in their 1st vs 15th year of practice had similar rates of 30-day serious complications (4.11% vs 3.89%; P = .11) and death (1.71% vs 1.70%; P = .93). CONCLUSIONS: Patients undergoing partial colectomy faced a higher risk of serious complications and death when the operation was performed by a new surgeon compared to an experienced surgeon. Conversely, patient outcomes following cholecystectomy were similar for new and experienced surgeons. More attention to partial colectomy during residency training may benefit patients.

Development, manufacture and initial assessment of validity of a 3-dimensional-printed bowel anastomosis simulation training model.

BACKGROUND: It is critical that junior residents be given opportunities to practise bowel anastomosis before performing the procedure in patients. Three-dimensional (3D) printing is an affordable way to provide realistic, reusable intestinal simulators. The aim of this study was to test the face and content validity of a 3D-printed simulator for bowel anastomosis. METHODS: The bowel anastomosis simulator was designed and assembled with the use of desktop 3D printers and silicone solutions. The production cost ranges from $2.67 to $131, depending on which aspects of the model one prefers to include. We incorporated input from a general surgeon regarding design modifications to improve the realism of the model. Nine experts in general surgery (6 staff surgeons and 3 senior residents) were asked to perform an anastomosis with the model and then complete 2 surveys regarding face and content validity. Items were rated on a 5-point Likert scale ranging from 1 ("strongly disagree") to 5 ("strongly agree"). RESULTS: The overall average score for product quality was 3.58, indicating good face validity. The average score for realism (e.g., flexibility and texture of the model) was 3.77. The simulator was rated as being useful for training, with an overall average score of 3.98. In general, the participants agreed that the simulator would be a valuable addition to current simulation-based medical education (average score 4.11). They commented that the model would be improved by adding extra layers to simulate mucosa. CONCLUSION: Experts found the 3D-printed bowel anastomosis simulator to be an appropriate tool for the education of surgical residents, based on the model's texture, appearance and ability to undergo an anastomosis. This model provides an affordable way for surgical residents to learn bowel anastomosis. Future research will focus on proving educational efficacy, effectiveness and transfer that can be adapted for laparoscopic anastomosis training, hand-sewing and stapling procedures.

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).

Colorectal Surgery Fellowship Improves In-hospital Mortality After Colectomy and Proctectomy Irrespective of Hospital and Surgeon Volume.

BACKGROUND: General surgery residents are increasingly pursuing sub-specialty training in colorectal (CR) surgery. However, the majority of operations performed by CR surgeons are also performed by general surgeons. This study aimed to assess in-hospital mortality stratified by CR training status after adjusting for surgeon and hospital volume. METHODS: The Statewide Planning and Research Cooperative system database was used to identify all patients who underwent colectomy/proctectomy from January 1, 2000, to December 31, 2014, in the state of New York. Operations performed by board-certified CR surgeons were identified. The relationships between CR board certification and in-hospital mortality, in-hospital complications, length of stay, and ostomy were assessed using multivariate regression models. RESULTS: Two hundred seventy thousand six hundred eighty-four patients underwent colectomy/proctectomy over the study period. Seventy-two thousand two hundred seventy-nine (26.7%) of operations were performed by CR surgeons. Without adjusting for hospital and surgeon volume, in-hospital mortality was lower for those undergoing colectomy/proctectomy by a CR surgeon (OR 0.49, CI 0.44-0.54, p = 0.001). After controlling for hospital and surgeon volume, the odds of inpatient mortality after colectomy/proctectomy for those operated on by CR surgeons weakened to 0.76 (CI 0.68-0.86, p = 0.001). Hospital and surgeon volume accounted for 53% of the reduction in in-hospital mortality when CR surgeons performed colectomy/proctectomy. Patients who underwent surgery by a CR surgeon had a shorter inpatient stay (0.8 days, p = 0.001) and a decreased chance of colostomy (OR 0.86, CI 0.78-0.95, p < 0.001). CONCLUSIONS: For patients undergoing colectomy/proctectomy, in-hospital mortality decreased when the operation was performed by a CR surgeon even after accounting for hospital and surgeon volume.

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.

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.

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.

[Comparison of the results of laparotomy and laparoscopic surgery in patients with Crohn's disease]. / A nyitott és minimálisan invazív beavatkozások eredményeinek összehasonlítása Crohn-betegségben.

INTRODUCTION: Crohn's disease is an inflammatory bowel disease which may affect different parts of the gastrointestinal tract. AIM: To compare retrospectively the results of laparotomy and laparoscopic surgery performed in patients with Crohn's disease between January 1, 2005 and October 31, 2012 in the Department of Surgery, University of Szeged, Hungary. METHOD: Patients were divided into two groups based on the types of surgery; 103 patients underwent laparotomy and 30 patients had laparoscopic surgery programmed. 22 patients had 24 primary acute interventions. RESULTS: The mean age was significantly lower in the laparoscopic surgery group (p = 0.042). The laparoscopic ileocecal resections have been found significantly shorter than laparotomies (p = 0.033). When ileocecal resection was performed the operation time was significantly longer (p = 0.033) while hospitalization time (p = 0.025) and intensive care unit treatment time (p<0.001) were shorter and the bowel passage also started earlier in the laparoscopic group as compared to the laparotomy group. CONCLUSIONS: Laparoscopic surgery results in smaller surgical trauma, better cosmetic outcome, shorter hospitalization time and not higher complication- and morbidity-rate as well as shorter operation time in certain cases. However, it requires more qualified surgical team and the operation expenses are higher.

Assessment of the role of aptitude in the acquisition of advanced laparoscopic surgical skill sets: results from a virtual reality-based laparoscopic colectomy training programme.

PURPOSE: The surgeons of the future will need to have advanced laparoscopic skills. The current challenge in surgical education is to teach these skills and to identify factors that may have a positive influence on training curriculums. The primary aim of this study was to determine if fundamental aptitude impacts on ability to perform a laparoscopic colectomy. METHODS: A practical laparoscopic colectomy course was held by the National Surgical Training Centre at the Royal College of Surgeons in Ireland. The course consisted of didactics, warm-up and the performance of a laparoscopic sigmoid colectomy on thesimulator. Objective metrics such as time and motion analysis were recorded. Each candidate had their psychomotor and visual spatial aptitude assessed. The colectomy trays were assessed by blinded experts post procedure for errors. RESULTS: Ten trainee surgeons that were novices with respect to advanced laparoscopic procedures attended the course. A significant correlation was found between psychomotor and visual spatial aptitude and performance on both the warm-up session and laparoscopic colectomy (r > 0.7, p < 0.05). Performance on the warm-up session correlated with performance of the laparoscopic colectomy (r = 0.8, p = 0.04). There was also a significant correlation between the number of tray errors and time taken to perform the laparoscopic colectomy (r = 0.83, p = 0.001). CONCLUSION: The results have demonstrated that there is a relationship between aptitude and ability to perform both basic laparoscopic tasks and laparoscopic colectomy on a simulator. The findings suggest that there may be a role for the consideration of an individual's inherent baseline ability when trying to design and optimise technical teaching curricula for advanced laparoscopic procedures.

Advanced fellowship training is associated with improved lymph node retrieval in colon cancer resections.

BACKGROUND: Examination of at least 12 lymph nodes has been established as the standard of care for adequate staging of colon cancer. The purpose of this study was to determine whether surgeon fellowship training, patient body mass index (BMI), and surgical approach (open versus laparoscopic) are important factors associated with lymph node retrieval at an NCI/NCCN-designated center. METHODS: We conducted a retrospective review of patients undergoing colectomy for colon cancer from 1994 to 2009. Patients who underwent right, left, and sigmoid colectomy by open or laparoscopic approaches were included. Lymph node retrieval and risk factors for inadequate nodal retrieval (<12 nodes) were analyzed. RESULTS: A total of 371 patients were included. Lymph node retrieval was found to be significantly increased when surgeons had fellowship training compared with no advanced training (19.9 ± 10.6 versus 14.8 ± 10.6, P = 0.0007). Lymph node retrieval was found to be significantly decreased in obese patients (BMI ≥ 30) compared with non-obese patients (17.3 ± 10.0 versus 19.9 ± 11.5, P = 0.05). There was no significant difference between open and laparoscopic approaches. On multivariate analysis, lack of fellowship training, surgery performed prior to establishment of NCI guidelines for lymph node retrieval, and small tumor size were independent predictors of inadequate lymph node retrieval. CONCLUSION: Advanced fellowship training of surgeons appears to be associated with higher lymph node retrieval and decreased risk of performing inadequate nodal retrieval. Small tumor size and surgery performed prior to establishment of the 12 lymph node benchmark were also associated with inadequate nodal retrieval.

Does the learning curve during laparoscopic colectomy adversely affect costs?

BACKGROUND: This study aimed to investigate whether the learning curve during laparoscopic colectomy is associated with increased costs compared with the procedure after the learning curve has been achieved. METHODS: The direct costs for patients undergoing laparoscopic colectomy during the learning curve (group A) and after the attainment of proficiency by two colorectal surgeons performing the procedure (group B) between 2001 and 2007 were compared. The learning curve was defined as the first 40 laparoscopic colectomy cases for each surgeon. The distribution of cases for the surgeons ensured that cost-related differences were not influenced by lead time bias of cases performed during the learning curve. RESULTS: The study involved 80 group A and 74 group B patients. Groups A and B were similar in terms of age (P = 0.7), gender (P = 0.5), American Society of Anesthesiologists (ASA) score (P = 0.5), body mass index (P = 0.3), diagnosis (P = 0.8), previous abdominal surgery (P = 0.07), and comorbidity (P = 0.4). The two groups also were similar with regard to performance of anastomosis (P = 0.2) or resection (P = 0.6), conversion to open surgery (P = 0.7), postoperative morbidity (P = 0.6), readmission (P = 0.1), reoperation rate (P = 0.6), and hospital length of stay (P = 0.6). The operation time was significantly longer for group A (P = 0.01). The total direct costs (P = 0.7) and the operating room (P = 0.6), nursing (P = 0.7), pharmacy (P = 0.9), radiology (P = 1), and professional (P = 0.051) costs were however similar between the two groups. CONCLUSIONS: As expected, laparoscopic colectomy during the learning curve period is associated with prolonged operating time. Concerns pertaining to increased conversions, complications, and direct costs during this period were not substantiated in this study.

Does specialized surgical training increase lymph node yield in colon cancer?

Most colon cancer resections do not meet the 12-lymph node minimum recommended in 2001 National Cancer Institute (NCI) panel guidelines. Previous reports suggest surgical training influences lymph node recovery. We hypothesized that recent trends show improved results for lymphadenectomy regardless of specialty. The cancer registry database at a large community hospital with an academic surgical oncology training program was queried to identify resections performed for colon cancer before (1995 to 2000) and after (2001 to 2006) NCI guideline publication. There were no changes in pathology procedures between 374 early and 411 later procedures. The later period brought increases in mean total lymph nodes (15.4 vs 10.4, P < 0.0001), total positive nodes (1.8 vs 1.2, P = 0.005), and the percentage of procedures yielding 12 or more nodes (overall: 65.9 vs 36.0%, P < 0.0001; Stage II and III disease: 73.0 vs 41.4%, P < 0.003). In addition, mean nodal yield increased (P < 0.0001) for fellowship-trained surgeons (16.7 vs 11.2) and nonfellowship-trained surgeons (14.9 vs 10.2). Single-registry data show that since 2001, most colon resections exceed minimum recommendations for lymph node recovery regardless of surgical training. The increased rate of adequate lymphadenectomy for Stage II and III disease is encouraging because this patient population will benefit most by accurate staging of colon cancer.

A model for longitudinal mentoring and telementoring of laparoscopic colon surgery.

OBJECTIVE: To demonstrate the feasibility of longitudinal mentoring and telementoring of community surgeons in laparoscopic colon surgery. METHODS: A mentoring protocol was established between a university centre and surgeons at a community hospital 60 km away. The community surgeons (CS) attended a course on laparoscopic colon surgery before observing surgery at the mentoring institution. Patients were identified from the CS practice and referred for formal consultation with the mentor. The mentor worked with the same two CS on every case in their local hospital. Procedure outcomes were recorded using Canadian Advanced Endoscopic Surgery Registry (CAESaR) practice audit software. The mentoring endpoint was 20 cases based on American Society of Colon and Rectal Surgeons (ASCRS)/Society of Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines. RESULTS: From March 2006 to August 2007, 40 patients underwent elective colon surgery by the CS, 20 of whom were referred and accepted for laparoscopic mentoring. After nine cases the MS did not scrub. Beginning with case 15, procedures were telementored except for a subtotal colectomy for which the MS assisted. Patients selected for mentoring (7 female, 13 male) compared with open cases (8 female, 12 male) were younger (60 +/- 13 years versus 72 +/- 17 years, p = 0.013), less likely to have cancer (50% versus 70%, p = 0.33)) and tended to require less complex resections. There were no conversions. Mentored cases took longer (150 +/- 43 min versus 108 +/- 40 min, p = 0.003) but resulted in shorter hospital stay (median 2.5 versus 7.0 days, p < 0.001). Median number of lymph nodes were equivalent in cancer resections (13 versus 12, p = 0.465) There were no technical difficulties with telementoring. Data will be recorded for a further 1 year to assess adoption rate and outcomes. CONCLUSIONS: This project demonstrates the feasibility of longitudinal mentoring and telementoring of laparoscopic colon surgery for cancer. This program may serve as a model for safe technology transfer to the community.

A new web-based operative skills assessment tool effectively tracks progression in surgical resident performance.

PURPOSE: The study aim was to demonstrate that a new database tool for assessment of surgical resident operative skills discerns predictable progression in those skills over successive residency years for specific index case types. METHODS: A Web-based interactive database (OpRate) was used to assess selected aspects of resident operative performance as determined by supervising attending surgeons in a medium-sized residency (5-6 residents per postgraduate year [PGY]). This assessment consisted of (1) 3 questions pertaining to patient information, technical, and disease-specific preparedness; (2) 4 laparoscopic technical skills questions pertaining to tissue handling, dexterity, planning, and ability to function independently; and (3) similar open technical skills questions, with the addition of 2 questions defining knot tying ability. Two years of assessment data were examined for cholecystectomy (CH), appendectomy (AP), colon resection (CR), ventral hernia repair (VH), and inguinal hernia repair (IH). Mean scores for total, technical, and preparedness responses, as well as each response area were compared for successive training years for each case type. Mean performance data between postgraduate years were compared by ANOVA, and interitem reliability was assessed by Cronbach's alpha determinations. RESULTS: OpRate data for 579 cases (142 CH, 67 AP, 73 CR, 202 IH, and 95 VH) were examined. Significant incremental increases in open and laparoscopic technical skills scores by training year were observed for all case types (ANOVA, p < 0.0001). Individual technical skills as well as technical and disease-specific preparedness response areas also demonstrated significant improvement by successive training year. Cronbach's alpha determinations were 0.80-0.94 for the preparedness test items and the skills performance scores for all assessed procedures. CONCLUSIONS: Our early results show that the OpRate assessment tool is effective in identifying expected changes in operative performance across successive training years, with a satisfactory level of internal consistency for the test items. As such, the use of this database tool may offer the opportunity to (1) define performance benchmarks for specific levels of training and (2) identify areas where focused training may be required for specific residents.

Implementation of laparoscopic colectomy with fast-track care in an academic medical center: benefits of a fully ascended learning curve and specialty expertise.

BACKGROUND: There are few data describing successful institutional "conversion" from open colectomy/standard care techniques to laparoscopic colectomy/fast-track care. PURPOSE: To assess the benefits of transitioning an institution from open to laparoscopic colectomy with fast-track care while avoiding a learning curve. METHOD: Twenty consecutive laparoscopic colorectal resections (LCRs) performed by a colorectal surgeon were compared with 20 matched open colorectal resections (OCRs) performed by general surgeons before the arrival of the colorectal surgeon. RESULTS: Surgical procedures were as follows: sigmoidectomy: OCR 16 and LCR 11; right colectomy: OCR 3 and LCR 8; and total colectomy: OCR 1 and LCR 1. The mean operative time for sigmoidectomy was 250 and 109 minutes for OCR and LCR, respectively, and for right colectomy 181 and 97 minutes for OCR and LCR, respectively (P < .001). Morbidity was OCR 45% versus LCR 25%. There was no mortality. LCR showed significantly lower length of stay and direct cost (3.6 vs. 8.3 days; 4,993 dollars vs. 11,383 dollars; both P < .001). CONCLUSIONS: The data clearly show an institutional benefit for the implementation of specialty-based advanced laparoscopic procedures.

Self-assessment during a 2-day laparoscopic colectomy course: can surgeons judge how well they are learning new skills?

BACKGROUND: The objectives of this study were to (1) establish the utility of an assessment tool for participants in a laparoscopic colectomy course and (2) to determine the accuracy of technical skill self-assessment in this group. METHODS: Twenty-two surgeons enrolled in a 2-day course participated. During the animal laboratory, each participant's operative performance was videotaped. Participants completed a global rating scale (GRS) instrument to self-assess their performances. By using the same GRS, 2 trained raters independently assessed each performance by videotape review. RESULTS: For the trained raters, the GRS showed excellent interrater reliability (r = .76, P < .001). There was no correlation between trained rater scores and self-assessment scores. Furthermore, the trained rater scores (mean, 2.62 and 2.99) were significantly lower than the self-assessment scores (4.05, P < .001). CONCLUSIONS: Surgeons consistently overestimated their performance during a laparoscopic colectomy course as measured by reliable GRS. This finding highlights the issue of credentialing and the importance of preceptorship for surgeons completing such courses.

The "cost" of operative training for surgical residents.

HYPOTHESIS: There is an increase in the amount of time required to perform an operation when the procedure involves training a surgical resident. This increased time does not translate into a financial burden for the hospital. DESIGN: Retrospective review of prospectively collected data. During the study period, surgeons and residents were blinded to the study's intent. We compared the operative times of academic surgeons performing 4 common surgical procedures before and after the introduction of a postgraduate year 3 resident into a community teaching hospital. Between January 1, 2001, and June 30, 2002, 4 academic surgeons performed operations without a resident in a community hospital that was recently integrated into a tertiary medical center system. During that period, surgeons operated alone (hernia surgery) or assisted one another (laparoscopic cholecystectomy, colectomy, and carotid endarterectomy). From July 1, 2002, through March 31, 2003, these same 4 surgeons were assisted by a postgraduate year 3 resident on similar procedures. SETTING: Community hospital recently integrated into a tertiary medical center system. PARTICIPANTS: Four experienced academic surgeons operating in the community setting and patients undergoing 1 of 4 surgical procedures (inguinal hernia repair, laparoscopic cholecystectomy, partial colectomy, or carotid endarterectomy) from January 1, 2001, through March 31, 2003. INTERVENTION: The introduction of a postgraduate year 3 surgical resident rotation into a community hospital in which the same academic surgeons had been performing operations without a resident for 18 months. MAIN OUTCOME MEASURES: Mean operating time with and without a postgraduate year 3 resident participating in 4 common surgical procedures. Result For the 4 procedures studied, there was a significant increase in the operative time required to complete such procedures. CONCLUSIONS: There is an increased time cost associated with the operative training of surgical residents. This "cost" primarily impacts the attending surgeon.