Automatically rating trainee skill at a pediatric laparoscopic suturing task.

BACKGROUND: Minimally invasive surgeons must acquire complex technical skills while minimizing patient risk, a challenge that is magnified in pediatric surgery. Trainees need realistic practice with frequent detailed feedback, but human grading is tedious and subjective. We aim to validate a novel motion-tracking system and algorithms that automatically evaluate trainee performance of a pediatric laparoscopic suturing task. METHODS: Subjects (n = 32) ranging from medical students to fellows performed two trials of intracorporeal suturing in a custom pediatric laparoscopic box trainer after watching a video of ideal performance. The motions of the tools and endoscope were recorded over time using a magnetic sensing system, and both tool grip angles were recorded using handle-mounted flex sensors. An expert rated the 63 trial videos on five domains from the Objective Structured Assessment of Technical Skill (OSATS), yielding summed scores from 5 to 20. Motion data from each trial were processed to calculate 280 features. We used regularized least squares regression to identify the most predictive features from different subsets of the motion data and then built six regression tree models that predict summed OSATS score. Model accuracy was evaluated via leave-one-subject-out cross-validation. RESULTS: The model that used all sensor data streams performed best, achieving 71% accuracy at predicting summed scores within 2 points, 89% accuracy within 4, and a correlation of 0.85 with human ratings. 59% of the rounded average OSATS score predictions were perfect, and 100% were within 1 point. This model employed 87 features, including none based on completion time, 77 from tool tip motion, 3 from tool tip visibility, and 7 from grip angle. CONCLUSIONS: Our novel hardware and software automatically rated previously unseen trials with summed OSATS scores that closely match human expert ratings. Such a system facilitates more feedback-intensive surgical training and may yield insights into the fundamental components of surgical skill.

Minimally Invasive Surgery for Complicated Diverticulitis.

Recent guidelines recommend an individualized approach to recurrent uncomplicated diverticulitis, reflecting research showing that non-operative treatment is safe. Thus, the majority of operations for diverticulitis in the future may be for complicated indications. A laparoscopic approach may be used for both acute and chronic complicated diverticulitis in appropriate patients, as described in the American and European guidelines. However, a safe approach to minimally invasive surgery requires recognition when conditions deteriorate or are not suited to laparoscopy as well as knowledge of a variety of technical maneuvers that elucidate difficult anatomy and facilitate resection. Primary anastomosis with or without diversion can be performed safely, and ileostomy reversal is significantly less morbid than Hartmann's (colostomy) reversal. Success in laparoscopy can be achieved with the use of adjunct techniques and technologies, including ureteral stents, hand ports, and hybrid approaches. When completed successfully, a laparoscopic approach has been shown to confer decreased ileus, length of stay, post-operative pain, surgical site infection, and ventral hernia compared to an open approach.

Integration of Hands-On Team Training into Existing Curriculum Improves Both Technical and Nontechnical Skills in Laparoscopic Cholecystectomy.

OBJECTIVE: Nontechnical skills are an essential component of surgical education and a major competency assessed by the ACGME milestones project. However, the optimal way to integrate nontechnical skills training into existing curricula and then objectively evaluate the outcome is still unknown. The aim of this study was to determine the effect laparoscopic team-based task training would have on the nontechnical skills needed for laparoscopic surgery. DESIGN: 9 PGY-1 residents underwent an established training curriculum for teaching the knowledge and technical skills involved in laparoscopic cholecystectomy. Initial training involved a didactic session, expert-led practice on a porcine model in a simulated operating room and laparoscopic skills practice on a virtual reality trainer. Residents then performed a laparoscopic cholecystectomy on the same porcine model as a preintervention test. Three to four months following this, residents were subjected to specific nontechnical skills training involving 2 simple team-based laparoscopic tasks. They then practiced a further 4 to 6 hours on the virtual reality trainer. A repeat postintervention laparoscopic cholecystectomy was then performed 3 to 4 months after nontechnical skills training. Both the preintervention and postintervention laparoscopic cholecystectomies were audiovisually recorded and then evaluated by 2 independent surgeons in a blinded fashion. Technical skills were assessed using objective structured assessment of technical skills (OSATS) and a technique specific rating scale (TRS) that we developed for laparoscopic cholecystectomy. Nontechnical skills were assessed using nontechnical skills for surgeons (NOTSS). Residents also completed a survey at the beginning and end of the training. SETTING: Tertiary care, university based teaching institution. PARTICIPANTS: A total of 9 general surgery residents at the intern level. RESULTS: The mean OSATS score improved from 13.7 ± 1.24 to 26.7 ± 0.31 (p < 0.001), the mean TRS score improved from 6 ± 0.46 to 13.1 ± 0.36 (p < 0.001) and the mean NOTSS score improved from 21.7 ± 1.83 to 36.3 ± 0.87 (p < 0.001) following the training. There was a strong correlation between OSATS and NOTSS scores (Pearson's R = 0.98) and TRS and NOTSS (R = 0.94). The inter-rater agreement was 0.79 for NOTSS, 0.9 for OSATS, and 0.82 for TRS. Following completion of the training, residents self-reported improvements in exchanging information (p < 0.01), coordinating activities (p < 0.01) and coping with pressure in the operating room (p < 0.001). CONCLUSION: Simple, team-based nontechnical skills training for laparoscopic cholecystectomy that was separate from technical skills training led to a sustained increase in residents' nontechnical skills 3 to 4 months after training. This was associated with a self-reported improvement in many nontechnical skills based on resident survey. Based on these results, we recommend that such designated nontechnical skills training is a valid alternative to other methods such as coaching and debriefing. We, therefore, plan to continue our efforts to develop team-based simulation tasks aimed at improving nontechnical skills for multiple surgical modalities.

Can Simulated Team Tasks be Used to Improve Nontechnical Skills in the Operating Room?

OBJECTIVE: The purpose of this study was to understand the effect of a team-based surgical skills intervention on the technical and nontechnical skills of surgery residents. DESIGN: This was a prospective cohort study with pretesting or posttesting. We designed basic tasks for the assessment and learning of nontechnical skills in the operating room (OR). A total of 15 postgraduate year 1 residents performed an open gastrojejunostomy in a simulated OR setting (pretest), followed by training in the 3 team-based tasks designed to teach communication and teamwork, followed by performance of a gastrojejunostomy in the simulated OR (posttest). SETTING: Tertiary care, university-based teaching institution. PARTICIPANTS: A total of 15 general surgery residents at the intern level. RESULTS: The mean nontechnical skills for surgeons (NOTSS) score improved postteam task training (10.04 ± 0.33 vs. 12.14 ± 1.33). There was a concomitant increase in the objective structured assessment of technical skills (OSATS) score (18.56 ± 0.86 vs. 22.86 ± 0.15, p = 0.006). The percentage increases in OSATS and NOTSS score for each resident was similar (19.49 ± 4.8 % for NOTSS vs. 21.22 ± 4.92 % for OSATS, p = 0.502). CONCLUSION: Nontechnical skills positively correlate with the technical performance of a surgeon. Simple, easily designed tasks can be used to improve NOTSS in the OR. These team tasks and development of curricula based on them can be used to explicitly address one of the most important components of ACGME core competencies for surgical residents, namely interpersonal skills and communication.