Educational value of a novel telestration device for surgical coaching-a randomized controlled trial.

INTRODUCTION: Communication is fundamental to effective surgical coaching. This can be challenging for training during image-guided procedures where coaches and trainees need to articulate technical details on a monitor. Telestration devices that annotate on monitors remotely could potentially overcome these limitations and enhance the coaching experience. This study aims to evaluate the value of a novel telestration device in surgical coaching. METHODS: A randomized-controlled trial was designed. All participants watched a video demonstrating the task followed by a baseline performance assessment and randomization into either control group (conventional verbal coaching without telestration) or telestration group (verbal coaching with telestration). Coaching for a simulated laparoscopic small bowel anastomosis on a dry lab model was done by a faculty surgeon. Following the coaching session, participants underwent a post-coaching performance assessment of the same task. Assessments were recorded and rated by blinded reviewers using a modified Global Rating Scale of the Objective Structured Assessment of Technical Skills (OSATS). Coaching sessions were also recorded and compared in terms of mentoring moments; guidance misinterpretations, questions/clarifications by trainees, and task completion time. A 5-point Likert scale was administered to obtain feedback. RESULTS: Twenty-four residents participated (control group 13, telestration group 11). Improvements in some elements of the OSATS scale were noted in the Telestration arm but there was no statistical significance in the overall score between the two groups. Mentoring moments were more in the telestration Group. Amongst the telestration Group, 55% felt comfortable that they could perform this task independently, compared to only 8% amongst the control group and 82% would recommend the use of telestration tools here. CONCLUSION: There is demonstrated educational value of this novel telestration device mainly in the non-technical aspects of the interaction by enhancing the coaching experience with improvement in communication and greater mentoring moments between coach and trainee.

What is the educational value and clinical utility of artificial intelligence for intraoperative and postoperative video analysis? A survey of surgeons and trainees.

INTRODUCTION: Surgical complications often occur due to lapses in judgment and decision-making. Advances in artificial intelligence (AI) have made it possible to train algorithms that identify anatomy and interpret the surgical field. These algorithms can potentially be used for intraoperative decision-support and postoperative video analysis and feedback. Despite the very early success of proof-of-concept algorithms, it remains unknown whether this innovation meets the needs of end-users or how best to deploy it. This study explores users' opinion on the value, usability and design for adapting AI in operating rooms. METHODS: A device-agnostic web-accessible software was developed to provide AI inference either (1) intraoperatively on a live video stream (synchronous mode), or (2) on an uploaded video or image file (asynchronous mode) postoperatively for feedback. A validated AI model (GoNoGoNet), which identifies safe and dangerous zones of dissection during laparoscopic cholecystectomy, was used as the use case. Surgeons and trainees performing laparoscopic cholecystectomy interacted with the AI platform and completed a 5-point Likert scale survey to evaluate the educational value, usability and design of the platform. RESULTS: Twenty participants (11 surgeons and 9 trainees) evaluated the platform intraoperatively (n = 10) and postoperatively (n = 11). The majority agreed or strongly agreed that AI is an effective adjunct to surgical training (81%; neutral = 10%), effective for providing real-time feedback (70%; neutral = 20%), postoperative feedback (73%; neutral = 27%), and capable of improving surgeon confidence (67%; neutral = 29%). Only 40% (neutral = 50%) and 57% (neutral = 43%) believe that the tool is effective in improving intraoperative decisions and performance, or beneficial for patient care, respectively. Overall, 38% (neutral = 43%) reported they would use this platform consistently if available. The majority agreed or strongly agreed that the platform was easy to use (81%; neutral = 14%) and has acceptable resolution (62%; neutral = 24%), while 30% (neutral = 20%) reported that it disrupted the OR workflow, and 20% (neutral = 0%) reported significant time lag. All respondents reported that such a system should be available "on-demand" to turn on/off at their discretion. CONCLUSIONS: Most found AI to be a useful tool for providing support and feedback to surgeons, despite several implementation obstacles. The study findings will inform the future design and usability of this technology in order to optimize its clinical impact and adoption by end-users.

Technical Performance as a Predictor of Clinical Outcomes in Laparoscopic Gastric Cancer Surgery.

OBJECTIVE: The purpose of this study was to evaluate the relationship between technical performance and patient outcomes in laparoscopic gastric cancer surgery. BACKGROUND: Laparoscopic gastrectomy for cancer is an advanced procedure with high rate of postoperative morbidity and mortality. Many variables including patient, disease, and perioperative management factors have been shown to impact postoperative outcomes; however, the role of surgical performance is insufficiently investigated. METHODS: A retrospective review was performed for all patients who had undergone laparoscopic gastrectomy for cancer at 3 teaching institutions between 2009 and 2015. Patients with available, unedited video-recording of their procedure were included in the study. Video files were rated for technical performance, using Objective Structured Assessments of Technical Skills (OSATS) and Generic Error Rating Tool instruments. The main outcome variable was major short-term complications. The effect of technical performance on patient outcomes was assessed using logistic regression analysis with backward selection strategy. RESULTS: Sixty-one patients with available video recordings were included in the study. The overall complication rate was 29.5%. The mean Charlson comorbidity index, type of procedure, and the global OSATS score were included in the final predictive model. Lower performance score (OSATS ≤29) remained an independent predictor for major short-term outcomes (odds ratio 6.49), while adjusting for comorbidities and type of procedure. CONCLUSIONS: Intraoperative technical performance predicts major short-term outcomes in laparoscopic gastrectomy for cancer. Ongoing assessment and enhancement of surgical skills using modern, evidence-based strategies might improve short-term patient outcomes. Future work should focus on developing and studying the effectiveness of such interventions in laparoscopic gastric cancer surgery.

The Effect of Technical Performance on Patient Outcomes in Surgery: A Systematic Review.

OBJECTIVE: Systematic review of the effect of intraoperative technical performance on patient outcomes. BACKGROUND: The operating room is a high-stakes, high-risk environment. As a result, the quality of surgical interventions affecting patient outcomes has been the subject of discussion and research for years. METHODS: MEDLINE, EMBASE, PsycINFO, and Cochrane databases were searched. All surgical specialties were eligible for inclusion. Data were reviewed in regards to the methods by which technical performance was measured, what patient outcomes were assessed, and how intraoperative technical performance affected patient outcomes. Quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). RESULTS: Of the 12,758 studies initially identified, 24 articles (7775 total participants) were ultimately included in this review. Seventeen studies assessed the performance of the faculty alone, 2 assessed both the faculty and trainees, 1 assessed trainees alone, and in 4 studies, the level of the operating surgeon was not specified. In 18 studies, a performance assessment tool was used. Patient outcomes were evaluated using intraoperative complications, short-term morbidity, long-term morbidity, short-term mortality, and long-term mortality. The average MERSQI score was 11.67 (range 9.5-14.5). Twenty-one studies demonstrated that superior technical performance was related to improved patient outcomes. CONCLUSIONS: The results of this systematic review demonstrated that superior technical performance positively affects patient outcomes. Despite this initial evidence, more robust research is needed to directly assess intraoperative technical performance and its effect on postoperative patient outcomes using meaningful assessment instruments and reliable processes.

Setting Performance Standards for Technical and Nontechnical Competence in General Surgery.

OBJECTIVES: The objectives of this study were to (1) create a technical and nontechnical performance standard for the laparoscopic cholecystectomy, (2) assess the classification accuracy and (3) credibility of these standards, (4) determine a trainees' ability to meet both standards concurrently, and (5) delineate factors that predict standard acquisition. BACKGROUND: Scores on performance assessments are difficult to interpret in the absence of established standards. METHODS: Trained raters observed General Surgery residents performing laparoscopic cholecystectomies using the Objective Structured Assessment of Technical Skill (OSATS) and the Objective Structured Assessment of Non-Technical Skills (OSANTS) instruments, while as also providing a global competent/noncompetent decision for each performance. The global decision was used to divide the trainees into 2 contrasting groups and the OSATS or OSANTS scores were graphed per group to determine the performance standard. Parametric statistics were used to determine classification accuracy and concurrent standard acquisition, receiver operator characteristic (ROC) curves were used to delineate predictive factors. RESULTS: Thirty-six trainees were observed 101 times. The technical standard was an OSATS of 21.04/35.00 and the nontechnical standard an OSANTS of 22.49/35.00. Applying these standards, competent/noncompetent trainees could be discriminated in 94% of technical and 95% of nontechnical performances (P < 0.001). A 21% discordance between technically and nontechnically competent trainees was identified (P < 0.001). ROC analysis demonstrated case experience and trainee level were both able to predict achieving the standards with an area under the curve (AUC) between 0.83 and 0.96 (P < 0.001). CONCLUSIONS: The present study presents defensible standards for technical and nontechnical performance. Such standards are imperative to implementing summative assessments into surgical training.

Practice does not always make perfect: need for selection curricula in modern surgical training.

BACKGROUND: It is hypothesized that not all surgical trainees are able to reach technical competence despite ongoing practice. The objectives of the study were to assess a trainees' ability to reach technical competence by assessing learning patterns of the acquisition of surgical skills. Furthermore, it aims to determine whether individuals' learning patterns were consistent across a range of open and laparoscopic tasks of variable difficulty. METHODS: Sixty-five preclinical medical students participated in a training curriculum with standardized feedback over forty repetitions of the following laparoscopic and open technical tasks: peg transfer (PT), circle cutting (CC), intracorporeal knot tie (IKT), one-handed tie, and simulated laparotomy closure. Data mining techniques were used to analyze the prospectively collected data and stratify the students into four learning clusters. Performance was compared between groups, and learning curve characteristics unique to trainees who have difficulty reaching technical competence were quantified. RESULTS: Top performers (22-35%) and high performers (32-42%) reached proficiency in all tasks. Moderate performers (25-37%) reached proficiency for all open tasks but not all laparoscopic tasks. Low performers (8-15%) failed to reach proficiency in four of five tasks including all laparoscopic tasks (PT 7.8%; CC 9.4%; IKT 15.6%). Participants in lower performance clusters demonstrated sustained performance disadvantage across tasks, with widely variable learning curves and no evidence of progression towards a plateau phase. CONCLUSIONS: Most students reached proficiency across a range of surgical tasks, but low-performing trainees failed to reach competence in laparoscopic tasks. With increasing use of laparoscopy in surgical practice, screening potential candidates to identify the lowest performers may be beneficial.

Implementation of an Effective Strategy for Teaching Nontechnical Skills in the Operating Room: A Single-blinded Nonrandomized Trial.

OBJECTIVE: To evaluate the effectiveness of debriefing and feedback on intraoperative nontechnical performance as an instructional strategy in surgical training. BACKGROUND: Regulatory authorities for accreditation in North America have included nontechnical skills such as communication and teamwork in the competencies to be acquired by surgical residents before graduation. Concrete recommendations regarding the training and assessment of these competencies, however, are lacking. METHODS: Nonrandomized, single-blinded study using an interrupted time-series design. Eleven senior surgical residents were observed during routine cases in the operating room (OR) at baseline and post-training. The Non-Technical Skills for Surgeons (NOTSS) rating system was used. Observers were trained in NOTSS and blinded to the study purpose. Independent of the blinded observations, a surgeon educator conducted intraoperative observations, which served as the basis for the structured debriefing and feedback intervention. The intervention was administered to participants after a set of (blinded) baseline observations had been completed. Primary outcome was nontechnical performance in the OR as measured by the NOTSS system. Secondary outcome was perceived utility as assessed by a post-training questionnaire. RESULTS: Twelve senior trainees were recruited, 11 completed the study. Average NOTSS scores improved significantly from 3.2 (SD 0.37) at baseline to 3.5 (SD 0.43) post-training [t(10) = -2.55, P = 0.29]. All participants felt the intervention was useful, and the majority thought that debriefing and feedback on nontechnical skills should be integrated in surgical training. CONCLUSIONS: Debriefing and feedback in the OR may represent an effective strategy to ensure development of nontechnical skills in competency-based education.

Educational interventions to improve ergonomics in gastrointestinal endoscopy: a systematic review.

Background and study aims Endoscopists are at high risk of musculoskeletal pain and injuries (MSPI). Recently, ergonomics has emerged as an area of interest to reduce and prevent the incidence of MSPI in endoscopy. The aim of this systematic review was to determine educational interventions using ergonomic strategies that target reduction of endoscopist MSPI from gastrointestinal endoscopy. Methods In December 2020, we conducted a systematic search in MEDLINE, EMBASE, PsycINFO, Web of Science, Scopus, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews for articles published from inception to December 16, 2020. Studies were included if they investigated educational interventions aimed at changing knowledge and/or behaviors related to ergonomics in gastrointestinal endoscopy. After screening and full-text review, we extracted data on study design, participants, type of training, and assessment of primary outcomes. We evaluated study quality with the Medical Education Research Study Quality Instrument (MERSQI). Results Of the initial 575 records identified in the search, five met inclusion criteria for qualitative synthesis. We found that most studies (n = 4/5, 80 %) were single-arm interventional studies that were conducted in simulated and/or clinical settings. The most common types of interventions were didactic sessions and/or videos (n = 4/5, 80%). Two (40 %) studies used both standardized assessment studies and formal statistical analyses. The mean MERSQI score was 9.7. Conclusions There is emerging literature demonstrating the effectiveness of interventions to improve ergonomics in gastrointestinal endoscopy.

The Effect of Tissue Adhesive on Surgical Site Infection Following Elective Bariatric Surgery: a Retrospective Cohort Study.

PURPOSE: The reported incidence of surgical site infection (SSI) following bariatric surgery ranges from 1.4 to 30%. The use of skin staples and tissue adhesive was shown to be superior to sutures in reducing SSI in a variety of surgical disciplines; however, this area is under-investigated in elective bariatric surgery. The aim of this study was to examine the effect of tissue adhesive for skin closure on SSI in patients undergoing bariatric surgery. METHODS: A retrospective analysis was performed to determine the incidence of SSI in patients who underwent elective laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG). Tissue adhesive was selectively used for skin closure during the study period. Patient characteristics, operative data, and 30-day postoperative outcomes were collected from patient charts and the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. RESULTS: A total of 1,579 patients were included in the study. Tissue adhesive was used in 31.2% of all operations (n = 494). The rate of incisional SSI in our study was 2.2% (n = 35). The use of tissue adhesive was more common in patients who developed incisional SSI compared with those without incisional SSI (54.3 vs. 30.8%, p = 0.003). On multivariate analysis, the use of tissue adhesive remained an independent predictor for the development of incisional SSI (OR 2.77, p = 0.007). CONCLUSION: The use of tissue adhesive was an independent predictor for incisional SSI following elective bariatric surgery. This is the first study to report the effects of tissue adhesive in this patient population.

Operative management of recalcitrant marginal ulcers following laparoscopic Roux-en-Y gastric bypass for morbid obesity: a systematic review.

One of the short- and long-term complications following Roux-en-Y gastric bypass (RYGB) for morbid obesity is the development of marginal ulcers (MUs). Although chronic and recalcitrant/recurrent marginal ulcers (rMUs) are common, there is no consensus on their optimal management. The objective of this study was to perform a systematic review of the elective operative management of rMUs. A systematic search of the literature was conducted. Relevant databases were searched up to May 16, 2020. Articles were included if they met the following inclusion criteria: (1) bariatric patients were included as the study population, (2) laparoscopic RYGB was performed as the index operation, (3) study patients developed rMUs, and (4) MUs required elective operative (surgical, endoscopic) interventions. Quality of articles was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The search identified 3470 citations; of these, 16 observational studies were included. Elective management of rMUs consisted of endoscopic (oversewing ± stents) and surgical interventions (gastrojejunostomy revision, vagotomy, conversion to sleeve gastrectomy, subtotal/total gastrectomy, reversal to normal anatomy). Quality of the studies as assessed by the GRADE system was low to very low. Recalcitrant/recurrent MUs are challenging complications both for bariatric patients and for their treating surgeons. There are no established algorithms for the management of rMUs, and the currently available evidence in the literature is limited both in quantity and in quality. Future multicentre, multisurgeon, randomized, controlled trials are needed to address this issue.

Clinical Indicators of Postoperative Bleeding in Bariatric Surgery.

The purpose of this study was to evaluate the relationship between patient, clinical and laboratory characteristics, and bleeding after bariatric surgery. A retrospective chart review was performed for all patients, who underwent a laparoscopic Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy at our institution between March 2012 and May 2014. In total, 788 patients were included in this study. Seventeen patients had postoperative bleeding. The demographics, comorbidities, and preoperative medications were similar between the groups. Mean postoperative hemoglobin in the bleeding group was significantly lower (94 vs. 126; P<0.001) with a larger decrease from the baseline value (-43 vs. -12; P<0.001). The mean heart rate (91 vs. 81; P<0.001) and its increase from baseline (12 vs. -0.01; P<0.001) were significantly different in the bleeding patients. Postoperative hemoglobin and heart rate were associated with bleeding but not systolic blood pressure or patient characteristics. Further research is needed to develop a robust predictive model.

Training in Laparoscopic Gastric Cancer Surgery in the Western World: Current Educational Practices, Challenges, and Potential Opportunities at a Large University Centre.

OBJECTIVE: The purpose of this study was to explore and understand how surgeons distribute tasks during a laparoscopic gastrectomy for gastric cancer in an academic teaching environment. DESIGN: An anonymous, cross-sectional, census survey was used to poll trainees' and staff members' opinions pertaining to laparoscopic gastrectomy. SETTING: Academic and community tertiary teaching hospitals, affiliated with the University of Toronto. PARTICIPANTS: All surgeons, within the Department of General Surgery at the University of Toronto, who practice laparoscopic gastrectomy for gastric cancer, were invited to participate. All general surgery residents, postgraduate year 1-5, minimally invasive surgery and surgical oncology fellows at the University of Toronto were invited to participate. Overall response rate was 74.35% (n = 87/117). RESULTS: The results suggested that trainees do not routinely perform the major operative steps. Trainees agreed with faculty in this regard; however, there was a statistically significant difference in opinions, related to the degree of the perceived active operating of the trainees. There was also a difference in opinion, between trainees and faculty, regarding the common reasons for takeover. CONCLUSIONS: The present survey highlights that current level of active exposure of surgical trainees to laparoscopic gastric surgery might be insufficient. A lack of role clarity may further hinder an optimal educational experience during these cases. Adopting a stepwise approach, with task deconstruction, could optimize training. Additional training modalities may be required to ensure technical proficiency is acquired before independent practice.