Retrospective evaluation of a hand-sewn side-to-side intestinal anastomosis technique in dogs and cats.

Background: Hand-sewn intestinal resection and anastomosis are commonly performed in veterinary medicine. The outcome of the hand-sewn side-to-side anastomosis (SSA) technique has never been described and compared to other techniques in dogs and cats. Aim: The study aims to describe the side-to-side hand-sewn anastomosis technique in small animals and to compare it with the end-to-end technique. Methods: A retrospective evaluation of the clinical records of dogs and cats that underwent enterectomy between 2000 and 2020 and were treated with side-to-side or end-to-end anastomosis (EEA) was performed. Results: Of the 52 dogs and 16 cats included in the study, 19 dogs and 6 cats received an SSA, and the remaining received an EEA. No intraoperative complication was reported. However, short-term complication rates were comparable, and mortality rates in the EEA group were higher. At the same time, stenosis was a frequent complication of SSA and was never reported following EEA. Conclusion: End-to-end technique remains the gold standard for hand-sewn intestinal anastomosis in small animals. However, SSA can be considered for selected cases with acceptable morbidity and mortality rates.

Arthroscopic acetabular labrum suture.

It is essential to be aware of the anatomy and biomechanics of the acetabular labrum in order to understand why it should be conserved. Vascularization comes from the capsule and also from the bone. The joint side contains numerous nerve endings, which explains why labral lesions are painful. It is involved in joint stabilization by maintaining a negative pressure inside the joint able to resist distraction. It acts as a seal. There are two main suture techniques: trans- and peri-labral. Translabral suture is better suited to a wide and solid labrum free of degenerative lesions. Both techniques should be known, and may be associated. Results are comparable. It is essential to manage the underlying pathology responsible for the labral lesion. Joint degeneration is associated with poor prognosis. It needs to be recognized and discussed with the patient, to avoid unrealistic expectations.

A new technique for emergency cerclage: Guard suture method.

Objective The aim of this study was to introduce a novel technique to treat midtrimester cervical insufficiency with prolapsed membranes. Material and methods This retrospective study included patients with singleton pregnancies between 16 and 28 gestational weeks that underwent emergency cervical cerclage in a tertiary center. Patients were divided into two groups as McDonald method and guard suture method group according to the procedure they underwent. The following variables were recorded and evaluated: gestational age at cerclage, cervical length between the suture and external cervical os measured by transvaginal ultrasound on postoperative 1st and 7th day, gestational age at delivery, time between the procedure and delivery, intraoperative complications, newborn intensive care unit (NICU) admission, Apgar scores of neonates, and discharged alive newborns. Results During the study period, 38 patients underwent emergency cerclage procedure. Twenty-three were included in the McDonald group and 15 were in the guard suture group. The mean gestational age at the time of cerclage was 22.1 (17 -27) weeks and the mean gestational age at delivery was 33.9 (26- 38) weeks. Prolongation time between cerclage and delivery was 80.42 (1 - 140) days. Significantly higher 1st and 5th minutes Apgar scores and significantly lower NICU admission was found in the guard suture group (p = 0.04, p = 0.01 and p = 0.02, respectively). Conclusion In cases with cervical insufficiency and prolapsed membranes, emergency cerclage may prevent premature birth by prolonging pregnancy. Guard suture method is safe, effective, and easily applicable and can help obstetricians achieve better fetal and neonatal outcomes.

Online survey on uterotomy closure techniques in caesarean section.

OBJECTIVES: Uterine closure technique in caesarean section (CS) influences the rate of late complications in subsequent pregnancies. As no common recommendation on suture techniques exists, we developed a questionnaire to determine the techniques currently used and the frequencies of late complications. METHODS: The online questionnaire consisted of 13 questions and was sent to 648 obstetric hospitals (level I-IV) in Germany. Number of CS, rate of vaginal birth after caesarean section (VBAC), the type of uterus suturing technique and the frequency of uterine dehiscences, ruptures and placenta accreta spectrum (PAS) were queried. The answers were anonymous, and results were evaluated descriptively. RESULTS: The response rate was 24.7%. The mean CS rate was 27.3% (±6.2), the repeat CS rate 33.2% (±18.1). After CS, 46.2% (±20.2) women delivered vaginally. To close the uterotomy, 74.4% of hospitals used single layer continuous sutures, 16.3% single layer locked sutures, 3.8% interrupted sutures, 3.1% double layer continuous sutures and 2.5% used other suture techniques. The percentages of observed uterine dehiscences did not differ significantly between the different levels of care nor did the uterotomy suture techniques. CONCLUSIONS: There is no uniform suturing technique in Germany. A detailed description of suture technique in surgery reports is required to evaluate complications in subsequent pregnancies. National online surveys on obstetric topics are feasible and facilitate the discussion on the need to define a standardized uterine closure technique for CS.

Effective, simple and fast procedure for laparoscopic port-sites wounds closure.

The closure of port-sites wounds, as the ultimate step of surgical laparoscopic procedures, can be allowed by threads, staples, surgical glue or adhesive sutures. We describe a simple and easy skin suturing technique which saves time and provides significant surgical ergonomics.

Implementation of the ACS/ APDS Resident Skills Curriculum reveals a need for rater training: An analysis using generalizability theory.

BACKGROUND: The American College of Surgeons (ACS)/Association of Program Directors in Surgery (APDS) Resident Skills Curriculum includes validated task-specific checklists and global rating scales (GRS) for Objective Structured Assessment of Technical Skills (OSATS). However, it does not include instructions on use of these assessment tools. Since consistency of ratings is a key feature of assessment, we explored rater reliability for two skills. METHODS: Surgical faculty assessed hand-sewn bowel and vascular anastomoses in real-time using the OSATS GRS. OSATS were video-taped and independently evaluated by a research resident and surgical attending. Rating consistency was estimated using intraclass correlation coefficients (ICC) and generalizability analysis. RESULTS: Three-rater ICC coefficients across 24 videos ranged from 0.12 to 0.75. Generalizability reliability coefficients ranged from 0.55 to 0.8. Percent variance attributable to raters ranged from 2.7% to 32.1%. Pairwise agreement showed considerable inconsistency for both tasks. CONCLUSIONS: Variability of ratings for these two skills indicate the need for rater training to increase scoring agreement and decrease rater variability for technical skill assessments.

End-to-Side Microvascular Anastomosis on Rat Femoral Vessels Using Only 2-Throw Knot Interrupted Sututres - Evaluation of Feasibility and Patency Rates on Rat Femoral Vessels Model.

BACKGROUND: The use of a 3-throw knot for anastomosis by microvascular neurosurgeons is the usual standard. There is an inherent belief that the third throw adds extra security to the knot; however, the third throw can make the knot heavy and unbalanced and can exert undue extra pressure on the opposing walls of the small-caliber intracranial vessels. This study evaluated the feasibility and efficiency of 2-throw reef knot interrupted sutures for an end-to-side microvascular anastomosis. METHODS: A prospective observational study of end-to-side anastomosis using a femoral artery-to-vein model was performed in 30 Sprague-Dawley rats. All anastomoses were done using 2-throw reef knot interrupted sutures. Ten procedures each were done by the heel-first, toe-first, and classic 2-ends techniques. Individual parameters were recorded for analysis. The delayed patency was confirmed by reexploration after a mean duration of 19.82 ± 8.12 days. RESULTS: The overall patency rates were 100% in the immediate period and 96.43% (27 of 28) in the delayed period. The average clamping time, average suturing time, and the average time per suture were 65.48 ± 16.93 minutes, 40.94 ± 11.22 minutes, and 3.18 ± 1.10 minutes, respectively. Two rats died in the postoperative period. CONCLUSIONS: The end-to-side microvascular anastomosis with 2-throw reef knots is feasible, with excellent immediate and delayed patency rates.

A Continuous Suture Anastomosis Outperforms a Simple Interrupted Suture Anastomosis in Esophageal Elongation.

INTRODUCTION: Long-gap esophageal atresia represents a distinct entity among the esophageal atresia spectrum. In many patients, achieving a reasonable anastomosis depends on some millimeters of tissue. We aimed to determine what effect the suturing technique would have on esophageal ex vivo elongation as it may determine the strength of a primary anastomosis. MATERIALS AND METHODS: In an analysis of porcine esophagi from animals for slaughter (100-120 days old with a weight of 100-120 kg), we determined esophageal length gain of simple continuous and simple interrupted suture anastomoses subjected to linear traction until linear breaking strength was reached. Statistical power of 80% was ensured based on an a priori power analysis using five specimens per group in a separate exploratory experiment. RESULTS: The simple continuous suture anastomosis in 15 porcine esophagi ( = 4.47 cm, 95% confidence interval: 4.08-4.74 cm) outperformed the simple interrupted suture anastomosis in another 15 esophagi ( = 3.03 cm, 95% confidence interval: 2.59-3.43 cm) in length gain (Δ = 1.44 cm, 95% confidence interval: 0.87-2.01 cm, p < 0.0001). CONCLUSION: Simple continuous anastomoses achieved higher length gain compared with simple interrupted suture anastomoses. This effect warrants an experimental assessment in vivo to assess its potential merits for clinical applicability.

Use of barbed suture without fashioning the "classical" Wirsung-jejunostomy in a modified end-to-side robotic pancreatojejunostomy.

BACKGROUND: The treatment of the pancreatic stump is a critical step of pancreatoduodenectomy (PD). Robot-assisted surgery (RAS) can facilitate minimally invasive challenging abdominal procedures, including pancreatojejunostomy. However, one of the major limitations of RAS stems from its lack of tactile feedback that can lead to pancreatic parenchyma laceration during knot tying or during traction on the suture. Moreover, a Wirsung-jejunostomy is not always easy to execute, especially in cases with small diameter duct. Herein, we describe and video-report the technical details of a robotic modified end-to-side invaginated robotic pancreatojejunostomy (RmPJ) with the use of barbed suture instead of the "classical" Wirsung-jejunostomy. METHODS: The RmPJ technique consists of a double layer of absorbable monofilament running barbed suture (3-0 V-Loc), the outer layer is used to invaginate the pancreatic stump. Thereafter, a small enterotomy is made in the jejunum exactly opposite to the location of the pancreatic duct for stent insertion (usually 5 Fr) inside the duct. The internal layer provides a second barbed running suture placed between the pancreatic capsule/parenchyma and the jejunal seromuscular layer. RESULTS: A total of 14 patients underwent robotic PD with RmPJ at our Institution. The mean console time was (281.36 ± 31.50 min), while the mean operative time for fashioning the RmPJ was 37.31 ± 7.80 min. Ten out of 14 patients were discharged within postoperative day 8. No clinically relevant pancreatic fistulas were encountered, while two patients developed biochemical leaks. CONCLUSIONS: RmPJ is feasible and reproducible irrespective of pancreatic duct size and parenchyma, and can enhance the surgical workflow of this operation. Specifically, the use of barbed sutures allows the exploitation of the potential advantages of the RAS, while minimizing the negative effect caused by the main disadvantage of the robotic approach, its absence of tactile feedback, by ensuring uniform tension on the continuous suture lines used, especially during the reconstructive phase of the operation.

Video-Based Guided Simulation without Peer or Expert Feedback is Not Enough: A Randomized Controlled Trial of Simulation-Based Training for Medical Students.

BACKGROUND: Feedback is a pivotal cornerstone and a challenge in psychomotor training. There are different teaching methodologies; however, some may be less effective. METHODS: A prospective randomized controlled trial was conducted in 130 medical students to compare the effectiveness of the video-guided learning (VLG), peer-feedback (PFG) and the expert feedback (EFG) for teaching suturing skills. The program lasted 4 weeks. Students were recorded making 3-simple stitches (pre-assessment and post-assessment). The primary outcome was a global scale (OSATS). The secondary outcomes were performance time, specific rating scale (SRS) and the impact of the intervention (IOI), defined as the variation between the final and initial OSATS and SRS scores. RESULTS: No significant differences were found between PFG and EFG in post-assessment results of OSATS, SRS scores or in the IOI for OSATS and SRS scores. Post-assessment results of PFG and EFG were significantly superior to VLG in OSATS and SRS scores [(19.8 (18.5-21); 16.6 (15.5-17.5)) and (20.3 (19.88-21); 16.8 (16-17.5)) vs (15.7 (15-16); 13.3 (12.5-14)) (p < 0.05)], respectively. The results of PFG and EFG were significantly superior to VLG in the IOI for OSATS [7 (4.5-9) and 7.4 (4.88-10) vs 3.5 (1.5-6) (p < 0.05)] and SRS scores [5.4 (3.5-7) and 6.3 (4-8.5) vs 3.1 (1.13-4.88) (p < 0.05)], respectively. CONCLUSION: The video-guided learning methodology without any kind of feedback is not enough for teaching suturing skills compared to expert or peer feedback. The peer feedback methodology appears to be a viable alternative to handling the emerging demands in medical education.

Machine learning analyses of automated performance metrics during granular sub-stitch phases predict surgeon experience.

Automated performance metrics objectively measure surgeon performance during a robot-assisted radical prostatectomy. Machine learning has demonstrated that automated performance metrics, especially during the vesico-urethral anastomosis of the robot-assisted radical prostatectomy, are predictive of long-term outcomes such as continence recovery time. This study focuses on automated performance metrics during the vesico-urethral anastomosis, specifically on stitch versus sub-stitch levels, to distinguish surgeon experience. During the vesico-urethral anastomosis, automated performance metrics, recorded by a systems data recorder (Intuitive Surgical, Sunnyvale, CA, USA), were reported for each overall stitch (Ctotal) and its individual components: needle handling/targeting (C1), needle driving (C2), and suture cinching (C3) (Fig 1, A). These metrics were organized into three datasets (GlobalSet [whole stitch], RowSet [independent sub-stitches], and ColumnSet [associated sub-stitches] (Fig 1, B) and applied to three machine learning models (AdaBoost, gradient boosting, and random forest) to solve two classifications tasks: experts (≥100 cases) versus novices (<100 cases) and ordinary experts (≥100 and <2,000 cases) versus super experts (≥2,000 cases). Classification accuracy was determined using analysis of variance. Input features were evaluated through a Jaccard index. From 68 vesico-urethral anastomoses, we analyzed 1,570 stitches broken down into 4,708 sub-stitches. For both classification tasks, ColumnSet best distinguished experts (n = 8) versus novices (n = 9) and ordinary experts (n = 5) versus super experts (n = 3) at an accuracy of 0.774 and 0.844, respectively. Feature ranking highlighted Endowrist articulation and needle handling/targeting as most important in classification. Surgeon performance measured by automated performance metrics on a granular sub-stitch level more accurately distinguishes expertise when compared with summary automated performance metrics over whole stitches.

Can Intraoperative Video Recordings Contribute to Improving Laparoscopic Percutaneous Extraperitoneal Closure in Children with Inguinal Hernia and Prevent Recurrence? A Pilot Study.

Aim: We reviewed intraoperative video recordings (IVRs) of laparoscopic percutaneous extraperitoneal closure (LPEC) for inguinal hernia in children blindly to assess performance. Methods: IVRs of 183 LPEC performed between April 2013 and March 2016, graded by the operating surgeon as difficult (D; n = 8), straightforward (S; n = 96), or easy (E; n = 79), were scored by a panel of reviewers with advanced (group A; >400 LPEC cases; n = 5), intermediate (group I; 50-150 cases; n = 5), and basic (group B; <10 cases; n = 5) experience, according to suturing, dissection plane, vas/vessel dissection, bleeding, and peritoneal injury. They also allocated a recurrence risk rank (RRR; highest = 6; lowest = 1) for each IVR. Mean score variance for each IVR was also compared between reviewers. Results: There was one recurrence (R; 4-year-old male; level E). RRR were: 1, 2, and 2 for reviewers A, I, and B, respectively. Reviewer A scores for "suturing" and "bleeding," and reviewer I scores for "dissection plane" and "peritoneal injury" correlated significantly with RRR. No reviewer B scores correlated with RRR. Score variance between A and I and A and B for cases D1 and D2 were statistically significant. Conclusion: Advanced reviewers showed greatest variance, questioning the validity of whether experience alone improves surgical technique.

[Early effectiveness of minimally invasive open reduction and internal fixation versus arthroscopic double-tunnel suture fixation for tibial avulsion fracture of posterior cruciate ligament].

OBJECTIVE: To compare the early effectiveness of minimally invasive open reduction and internal fixation via posterior median approach versus arthroscopic double-tunnel suture fixation in treatment of tibial avulsion fracture of the posterior cruciate ligament (PCL). METHODS: A clinical data of 31 patients with the tibial avulsion fracture of the PCL and met the criteria between January 2015 and January 2019 was retrospectively analyzed. Nineteen patients (group A) were treated with open reduction and internal fixation with cannulated screw via posterior median approach. The other 12 patients (group B) were treated with arthroscopic double-tunnel suture fixation technique. There was no significant difference between the two groups ( P>0.05) in the gender, age, side of effected limb, the injury cause, the time from injury to operation, the combined meniscus injury, Meyers & McKeever classification and preoperative Lysholm score, Tegner score, International Knee Documentation Committee (IKDC) score, and the difference of tibial posterior displacement between bilateral knees. The operation time, postoperative complications, fracture healing, and the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score were recorded. RESULTS: Group B spent significantly longer operation time than group A ( t=7.347, P=0.000). No postoperative complication occurred in group B, and 1 patient in group A had a screw breakage. All patients were followed up 6-36 months (mean, 22 months). X-ray films showed that all fractures healed at 3 months after operation. At last follow-up, there was no significant difference in the patients with normal knee range of motion between the two groups ( P=0.510). At last follow-up, the difference of tibial posterior displacement between bilateral knees, Lysholm score, Tegner score, and IKDC score in the two groups were superior to those before operation ( P<0.05); while there was no significant difference between the two groups ( P>0.05). CONCLUSION: For the tibial avulsion fracture of PCL, the minimally invasive open reduction and internal fixation and arthroscopic double-tunnel suture fixation can obtain similar early effectiveness. However, arthroscopic surgery has the advantages of being able to simultaneously deal with intra-articular combined injuries, avoiding internal fixator complications, and eliminating the need for secondary operation.

Comparison of Primary Closure, Secondary Closure, and Limberg Flap in the Surgical Treatment of Pilonidal Cysts.

There are few studies comparing methods for pilonidal cyst closure. This study was conducted to compare simple surgical closure, secondary healing, and closure using a Limberg flap in the treatment of patients affected with pilonidal cysts. In total, 150 patients with pilonidal cysts were selected and randomized into 3 groups, with 50 participants in each group. Group A underwent primary closure, Group B underwent secondary closure, and Group C underwent closure with a Limberg flap. Operating time, amount of pain after surgery, time to mobilization, time until return to work, time for complete healing, time until being able to sit on the toilet without pain, postoperative complications including infection and recurrence, and seroma and edema after surgery were compared among the 3 groups. Duration of surgery in the Limberg flap group was significantly longer than the duration of surgery in Group A or Group B (p < .001). The time to patient mobilization, the time when the patient returned to work, the time to complete healing, and the time to being able to sit on the toilet without pain were significantly shorter in Group C than in Group A or Group B (p < .001). Although the procedure takes longer when using a Limberg flap, it appears to be a more effective method in the surgical treatment of patients with pilonidal cyst because of the reduced healing time and improved functional status after the procedure.

Evaluation of a new suture material (Duramesh™) by measuring suture tension in small and large bites techniques for laparotomy closure in a porcine model.

PURPOSE: After closure of laparotomies, sutures may pull through tissue due to too high intra-abdominal pressure or suture tension, resulting in burst abdomen and incisional hernia. The objective of this study was to measure the suture tension in small and large bites with a new suture material. METHODS: Closure of the linea alba was performed with small bites (i.e., 5 mm between two consecutive stitches and 5 mm distance from the incision) and large bites (i.e., 10 mm × 10 mm) with Duramesh™ size 0 (2 mm) and PDS II 2-0 in 24 experiments on six porcine abdominal walls. The abdominal wall was fixated on an artificial computer-controlled insufflatable abdomen, known as the 'AbdoMan'. A custom-made suture tension sensor was placed in the middle of the incision. RESULTS: The suture tension was significantly lower with the small bites technique and Duramesh™ when compared with large bites (small bites 0.12 N (IQR 0.07-0.19) vs. large bites 0.57 N (IQR 0.23-0.92), p < 0.025). This significant difference was also found in favour of the small bites with PDS II 2-0 (p < 0.038). No macroscopic tissue failure was seen during or after the experiments. CONCLUSION: Closure of the abdominal wall with the small bites technique and Duramesh™ was more efficient in dividing suture tension across the incision when compared to large bites. However, suture tension compared to a conventional suture material was not significantly different, contradicting an advantage of the new suture material in the prevention of burst abdomen and incisional hernia during the acute, postoperative phase.

Which Knots Are Recommended in Laparoscopic Surgery and How to Avoid Insecure Knots.

STUDY OBJECTIVE: To investigate why security of identical knot sequences is variable and how to avoid occasionally insecure knots. DESIGN: A factorial design was used to assess factors affecting the security of half knot (H) and half-hitch (S) knot combinations. The effect of tying forces and the risk factors to transform H knots into S knots were investigated. The risk factors evaluated were as follows: starting with an H1 or H2 instead of an H3 knot, inexperience, short sutures, and monomanual knot tying. Security of transformed knots, S2S1 and S2S2 knots, and their recuperation with 2 additional half hitches, SSb or SbSb, were evaluated. SETTING: Training center for laparoscopic suturing. PATIENTS: Not applicable. INTERVENTIONS: Security of knots was evaluated in vitro. MEASUREMENTS AND MAIN RESULTS: The forces that caused knot combinations to open before breaking of the suture were used to calculate the risk of opening with low forces. Tying more strongly increased the security of half knots (H2H1sH1s) (p <.02) and half hitches (p <.001). The forces needed to transform an H3 into an S3 are higher than those for an H2 (p <.001), and the risk increases when the surgeon is inexperienced (p <.001), when sutures are short (p <.001), and when monomanual knot tying (p <.001) is used. Inadvertently made S2S1 and S2S2 knots are dangerous, with the exception of the symmetric S2S2, which is stable. Unstable knots such as S2S1a and S2S2a knot combinations improve with 2 additional blocking half hitches (SbSb), but S2S2aSbSb remains occasionally insecure. CONCLUSION: To reduce the risk of accidentally transforming a first H into an S knot, it is recommended to start with an H3, tie with force, avoid short sutures, and use bimanual suturing. This permits the recommendation to use preferentially H3H2 knots or 5 half hitches (SSSbSbSb). When in doubt, half knot combinations should be secured with at least 2 blocking half hitches.

Implementation of the small bites closure of abdominal midline incisions in clinical practice is correlated with a reduction in surgical site infections.

BACKGROUND: Small steps wound closure of midline laparotomy has been reported to decrease the incidence of incisional hernia development in two randomized controlled trials. The aim of the present study was to evaluate the effect of implementing the small steps wound closure technique in clinical practice with regards to the development of incisional ventral hernia (IVH) and surgical site infections (SSI) in clinical practice. METHODS: Implementation of the small steps wound closure technique using the small tissue bites technique as the standard closure technique for abdominal midline incisions in our clinical practice was done in March 2015. For this study, all patients from June 2013 until June 2016 with a midline laparotomy, either long or small in case of specimen extraction in laparoscopic surgery, in either elective or emergency setting were included. Conventional large bite wound closure was compared to small steps wound closure with regards to the development of SSI, IVH as well as burst abdomen. RESULTS: A total of 327 patients were included. The small steps suture technique was used in 136 (42%) of the patients, whereas the conventional large bites suture technique was used in 191 patients (58%). A total of 54 patients in the large bites group developed SSI (28%) compared to 23 (17%) patients in the small steps group (p = 0.02). A total number of 10 patients (7%) developed IVH in the small steps group compared to 27 patients (14%) in the large bites group (p = 0.08). CONCLUSION: Implementation of small bites wound closure of abdominal midline incisions in clinical practice was correlated with a reduction in surgical site infections.

Spaced Education Improves the Retention of Laparoscopic Suturing Skills: A Randomized Controlled Study.

INTRODUCTION: Spaced learning has been shown to be superior in complex motor skill acquisition like laparoscopic suturing and knot tying. By using a pre-post follow-up design, the aim of the study was to evaluate the long-term impact of implementation of the spaced learning concept in laparoscopic training. MATERIALS AND METHODS: To evaluate the effectiveness of spaced learning, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes-prior and after 3 hours of hands-on training. To examine the long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 12 months later as follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation. RESULTS: Twenty students were included in the study; after simple randomization, 10 were trained using the "spaced learning" concept and 10 via traditional methods. Both groups had comparable baseline characteristics and improved after training significantly, regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of speed (p = 0.021), knot quality (p = 0.008), and suture strength (p = 0.003). Additionally, spaced learning significantly decreased anxiety (p = 0.029) and probability of success (p = 0.005). CONCLUSION: The spaced learning concept is very suitable for long-term complex motor skill acquisition, like laparoscopic suturing and knot tying. It is superior to conventional training regarding speed and, most importantly, knot quality and stability, resulting in improved confidence and motivation. Thus, we strongly recommend to incorporate the spaced learning concept into training courses and surgical programs.

What are the skills that represent expert-level laparoscopic suturing? A Delphi Study.

BACKGROUND: As the field of laparoscopic surgery grows, the need for a valid assessment of laparoscopic surgical skills becomes apparent. The objective of this study was to identify laparoscopic suturing skills reflective of performing at an expert level. METHODS: A Delphi Study was conducted with expert laparoscopic surgeons. Tasks were considered to meet criteria for consensus after 80% of survey participants answered "strongly agree." Results of the previous round of surveys were shared with participants at the start of the next round. The predefined endpoint for the Delphi was set as maximum of three rounds, reaching 80% consensus on each skill, or if > 50% of initial respondents fail to return for subsequent surveys. RESULTS: After three rounds of surveys completed by 13 advanced laparoscopic surgeons, 8 observed skills met consensus (> 80% selected "strongly agree"): forehand suturing, continuous suturing, avoiding tissue trauma, achieving a technically acceptable final product (tight closure), tying a secure knot at the end of suturing, maintaining/checking for appropriate tightness of running suture, accurate depth perception, and loading the needle in < 3 attempts. Skills that approached consensus (with > 50% ranking them as "strongly agree") included correct penetration of target tissue, ability to create a surgeon's knot, awareness of needle tip position, confined space suturing, following the curve of the needle, smooth movements of instruments, loading the needle correctly, adjusting for tissue thickness, and bimanual dexterity. CONCLUSIONS: Using Delphi methodology, we identified the skills that are representative of expert laparoscopic suturing. This information can be used to create an assessment tool for this domain. Validation of such a tool will help advance the surgical field towards true competency-based assessment of expertise.