Use of Simulation For Training Advanced Colorectal Procedures.

OBJECTIVE: Simulation training for minimally invasive colorectal procedures is in developing stages. This study aims to assess the impact of simulation on procedural knowledge and simulated performance in laparoscopic low anterior resection (LLAR) and robotic right colectomy (RRC). DESIGN: LLAR and RRC simulation procedures were designed using human cadaveric models. Resident case experience and simulation selfassessments scores for operative ability and knowledge were collected before and after the simulation. Colorectal faculty assessed resident simulation performance using validated assessment scales (OSATS-GRS, GEARS). Paired t-tests, unpaired t-tests, Pearson's correlation, and descriptive statistics were applied in analyses. SETTING: Barnes-Jewish Hospital/Washington University School of Medicine in St. Louis, Missouri. PARTICIPANTS: Senior general surgery residents at large academic surgery program. RESULTS: Fifteen PGY4/PGY5 general surgery residents participated in each simulation. Mean LLAR knowledge score increased overall from 10.0 ±  2.0 to 11.5  ±  1.6 of 15 points (p = 0.0018); when stratified, this increase remained significant for the PGY4 cohort only. Mean confidence in ability to complete LLAR increased overall from 2.0 ±  0.8 to 2.8  ± 0.9 on a 5-point rating scale (p = 0.0013); when stratified, this increase remained significant for the PGY4 cohort only. Mean total OSATS GRS score was 28  ±  6.3 of 35 and had strong positive correlation with previous laparoscopic colorectal experience (r = 0.64, p = 0.0092). Mean RRC knowledge score increased from 9.4 ±  2.2 to 11.1 ±  1.5 of 15 points (p = 0.0030); when stratified, this increase again remained significant for the PGY4 cohort only. Mean confidence in ability to complete RRC increased from 1.9 ±  0.9 to 3.2  ±  1.1 (p = 0.0002) and was significant for both cohorts. CONCLUSIONS: Surgical trainees require opportunities to practice advanced minimally invasive colorectal procedures. Our simulation approach promotes increased procedural knowledge and resident confidence and offers a safe complement to live operative experience for trainee development. In the future, simulations will target trainees on the earlier part of the learning curve and be paired with live operative assessments to characterize longitudinal skill progression.

National ABSITE Preparation Practices: A Survey of General Surgery Residency Program Directors.

OBJECTIVE: The American Board of Surgery In-Training Examination (ABSITE) was designed as a low-stakes, medical knowledge examination for US general surgery residency programs. However, in practice, this exam has been utilized for higher stakes purposes, such as resident promotion or remediation, and fellowship selection. Several studies have demonstrated the efficacy of ABSITE preparation resources, but best practices for ABSITE preparation and national preparatory habits are currently unknown. The aim of this work was to determine current residency programs' strategies for ABSITE preparation. DESIGN: We distributed an electronic survey to program directors or program coordinators of US general surgery programs asking them to anonymously report program ABSITE educational practices and ABSITE scores. We analyzed the proportion of responses using descriptive statistics and compared the effect of various strategies using the Mann-Whitney testing for nonparametric data. An average ABSITE percentile score was calculated for each residency based on program self-reported scores. SETTING: Association of Program Directors (APDS) Listserv PARTICIPANTS: General surgery residency programs participating at the time of distribution (278). RESULTS: Response rate was 24% (66/278); 41 programs (62.1%) identified as university-affiliated, and 25 (37.9%) were community-based. Median intern class size was 8 (range: 3-14), including preliminary interns. Average ABSITE percentile score was 52.8% (range 36.9%-67.6%). There were no significant differences in ABSITE scores based on affiliation or program size. Educational resources utilized for ABSITE preparation included SCORE (89.3%), Q-banks (50%), and surgical textbooks (25.8%). The majority (56.1%) of programs reported using a year-long curriculum for ABSITE preparation, and 66.6% used a time-limited curriculum completed in the months immediately prior to ABSITE. Most programs reported that ABSITE scores were a low priority (63.6%) or not a priority (13.6%). The existence of a year-long curriculum for ABSITE was positively correlated with score as compared to programs without a year-long curricula (53.9% vs 48.5%, p <0.01). Programs using a time-limited curriculum demonstrated lower scores as compared to programs without time-limited curricula (51.3% v 56.1%, p < 0.01). CONCLUSION: General surgery programs use a variety of strategies to prepare residents for the ABSITE. Despite reporting that they utilize ABSITE scores for a variety of high stakes purposes including evaluation for promotion and as a predictor of the preparedness for the ABS QE, many programs reported that they consider ABSITE scores as a low priority. A year-long focused curriculum was the only strategy correlated with increased scores, which may reflect the value of encouraging consistent studying and spaced repetition. Additional work is needed to guide programs in optimal utilization of ABSITE scores for remediation and resident evaluation, as well as understanding how ABSITE preparatory strategies correlate with clinical performance.

Use of targeted educational resources to improve robotic bariatric surgery training.

BACKGROUND: Evidence for how to best train surgical residents for robotic bariatric procedures is lacking. We developed targeted educational resources to promote progression on the robotic bariatric learning curve. This study aimed to characterize the effect of resources on resident participation in robotic bariatric procedures. METHODS: Performance metrics from the da Vinci Surgical System were retrospectively reviewed for sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) cases involving general surgery trainees with a single robotic bariatric surgeon. Pictorial case guides and narrated operative videos were developed for these procedures and disseminated to trainees. Percent active control time (%ACT)-amount of trainee console time spent in active instrument manipulations over total active time from both consoles-was the primary outcome measure following dissemination. One-way ANOVA, Student's t-tests, and Pearson correlations were applied. RESULTS: From September 2020 to July 2021, 50 cases (54% SG, 46% RYGB) involving 14 unique trainees (PGY1-PGY5) were included. From November 2021 to May 2022 following dissemination, 29 cases (34% SG, 66% RYGB) involving 8 unique trainees were included. Mean %ACT significantly increased across most trainee groups following resource distribution: 21% versus 38% for PGY3s (p = 0.087), 32% versus 45% for PGY4s (p = 0.0009), and 38% versus 57% for PGY5s (p = 0.0015) and remained significant when stratified by case type. Progressive trainee %ACT was not associated with total active time for SG cases before or after intervention (pre r = - 0.0019, p = 0.9; post r = - 0.039, p = 0.9). It was moderately positively associated with total active time for RYGB cases before dissemination (r = 0.46, p = 0.027) but lost this association following intervention (r = 0.16, p = 0.5). CONCLUSION: Use of targeted educational resources promoted increases in trainee participation in robotic bariatric procedures with more time spent actively operating at the console. As educators continue to develop robotic training curricula, efforts should include high-quality resource development for other sub-specialty procedures. Future work will examine the impact of increased trainee participation on clinical and patient outcomes.

The Advanced Certifying Exam Simulation-Pro assessment instrument: evaluating surgical trainee examsmanship in virtual oral exams.

Purpose: In response to the COVID-19 pandemic, many educational activities in general surgery residency have shifted to a virtual environment, including the American Board of Surgery (ABS) Certifying Exam. Virtual exams may become the new standard. In response, we developed an evaluation instrument, the ACES-Pro, to assess surgical trainee performance with a focus on examsmanship in virtual oral board examinations. The purpose of this study was two-fold: (1) to assess the utility and validity of the evaluation instrument, and (2) to characterize the unique components of strong examsmanship in the virtual setting, which has distinct challenges when compared to in-person examsmanship. Methods: We developed a 15-question evaluation instrument, the ACES-Pro, to assess oral board performance in the virtual environment. Nine attending surgeons viewed four pre-recorded oral board exam scenarios and scored examinees using this instrument. Evaluations were compared to assess for inter-rater reliability. Faculty were also surveyed about their experience using the instrument. Results: Pilot evaluators found the ACES-Pro instrument easy to use and felt it appropriately captured key professionalism metrics of oral board exam performance. We found acceptable inter-rater reliability in the domains of verbal communication, non-verbal communication, and effective use of technology (Guttmann's lambda-2 were 0.796, 0.916, and 0.739, respectively). Conclusions: The ACES-Pro instrument is an assessment with evidence for validity as understood by Kane's framework to evaluate multiple examsmanship domains in the virtual exam setting. Examinees must consider best practices for virtual examsmanship to perform well in this environment. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00107-7.

Thriving as a Surgical Intern: Three Tips From the Collaboration of Surgical Education Fellows (CoSEF).

We are the multi-institutional organization known as the Collaboration of Surgical Education Fellows (CoSEF). We've collectively reflected on our range of experiences across the country and identified 3 principles which promote a successful intern experience: (1) Own your patients; (2) Treat people like people; and (3) Take care of yourself.

The impact of virtual interviews on the Fellowship Council application and main match process.

BACKGROUND: The COVID-19 pandemic led the Fellowship Council (FC) to transition rapidly from in-person to virtual interviews. We investigated the impact of this transition on the FC application and main match process. METHODS: Five years (2018-2022) of deidentified FC applicant, program, and match rank data were used to assess differences between in-person (2018-2019) and virtual interview (2021-2022) cycles. Data are expressed as mean ± SD and one-way and two-way MANOVA tests were applied. RESULTS: Trainees applied to an average of 30.4 ± 24.3 programs and ranked an average of 10.7 ± 9.7 programs with a 57% match rate and average rank position of 3.6 ± 3.3. Fellowship programs received an average of 64.9 ± 28.6 applications and ranked an average of 15.4 ± 8.8 applicants with a 95% match rate and average applicant rank position of 3.0 ± 3.4. Applicants who interviewed virtually applied to a greater number of programs (32.7 vs. 27.0; p < 0.001) and ranked a greater number of programs (11.5 vs. 10.0; p = 0.004) with no difference in match rates (58% vs. 55%, p = 0.291). Among matched applicants, there was a significant difference in average rank position (3.20 vs. 4.30, p < 0.001), favoring the in-person cohort. Fellowship programs had more applicants per program (69.2 vs. 57.8; p < 0.001) and ranked more applicants (17.4 vs. 13.3; p < 0.001) during the virtual interview cycles. No difference in either match rates (93% vs. 96%, p = 0.178) or applicant rank position (3.09 vs. 2.93, p = 0.561) was seen between in-person and virtual application cycles. CONCLUSION: Virtual interviews were associated with an increased number of applications for fellowship and applicants ranked by programs but did not impact match rates of either group. Rank match position declined somewhat for applicants but not for fellowship programs. Virtual interviews offer more opportunities for applicants and a greater number of candidates for fellowship programs with only a slight decrement in fellow match rank position.

How Does Robotic-Assisted Surgery Change OR Safety Culture?

Robotic-assisted techniques in surgery require complex equipment setup and create surgeon isolation through loss of normal operative visual and auditory exchanges. These changes demand enhanced team communication and feedback in operating room settings so that robotic-assisted surgery does not compromise safe, efficient surgical care. Diverse simulation and training methods should be incorporated and studied based on local needs to determine how these techniques influence operating room communication, workflow, and safety culture.

Active control time: an objective performance metric for trainee participation in robotic surgery.

Trainee participation and progression in robotic general surgery remain poorly defined. Computer-assisted technology offers the potential to provide and track objective performance metrics. In this study, we aimed to validate the use of a novel metric-active control time (ACT)-for assessing trainee participation in robotic-assisted cases. Performance data from da Vinci Surgical Systems was retrospectively analyzed for all robotic cases involving trainees with a single minimally invasive surgeon over 10 months. The primary outcome metric was percent ACT-the amount of trainee console time spent in active system manipulations over total active time from both consoles. Kruskal-Wallis and Mann-Whitney U statistical tests were applied in analyses. A total of 123 robotic cases with 18 general surgery residents and 1 fellow were included. Of these, 56 were categorized as complex. Median %ACT was statistically different between trainee levels for all case types taken in aggregate (PGY1s 3.0% [IQR 2-14%], PGY3s 32% [IQR 27-66%], PGY4s 42% [IQR 26-52%], PGY5s 50% [IQR 28-70%], and fellow 61% [IQR 41-85%], p = < 0.0001). When stratified by complexity, median %ACT was higher in standard versus complex cases for PGY5 (60% vs. 36%, p = 0.0002) and fellow groups (74% vs. 47%, p = 0.0045). In this study, we demonstrated an increase in %ACT with trainee level and with standard versus complex robotic cases. These findings are consistent with hypotheses, providing validity evidence for ACT as an objective measurement of trainee participation in robotic-assisted cases. Future studies will aim to define task-specific ACT to guide further robotic training and performance assessments.

The efficacy of goal-directed recommendations in overcoming barriers to elective ventral hernia repair in older adults.

BACKGROUND: Although ventral hernias are common in older adults and can impair quality of life, multiple barriers exist that preclude ventral hernia repair. The goal of this study was to determine if older adults with ventral hernias achieve surgeon-directed goals to progress to an elective ventral hernia repair. METHODS: Patients ≥60 years evaluated for a ventral hernia in a specialty clinic from January 2018 to August 2021 were retrospectively reviewed. Nonoperative candidates with modifiable risk factors were included. Data collected included specific barriers to ventral hernia repair and recommendations to address these barriers for future ventral hernia repair eligibility. Patients lost to follow-up were contacted by phone. RESULTS: In total, 559 patients were evaluated, with 182 (32.6%) deemed nonoperative candidates with modifiable risk factors (median age 68 years, body mass index 38.2). Surgeon-directed recommendations included weight loss (53.8%), comorbidity management by a medical specialist (44.0%), and smoking cessation (19.2%). Ultimately, 45/182 patients (24.7%) met preoperative goals and progressed to elective ventral hernia repair. Alternatively, 5 patients (2.7%) required urgent/emergency surgical intervention. Importantly, 106/182 patients (58.2%) did not return to clinic after initial consultation. Of those contacted (n = 62), 35.5% reported failure to achieve optimization goals. Initial body mass index ≥40 and surgeon-recommended weight loss were associated with lack of patient follow-up (P = .01, P = .02) and progression to elective ventral hernia repair (P = .009, P = .005). CONCLUSION: Nearly one-third of older adults evaluated for ventral hernias were nonoperative candidates, most often due to obesity, and over half of these patients were lost to follow-up. An increase in structured support is needed for patients to achieve surgeon-specified preoperative goals.

A novel assessment model for teaching robot-assisted living donor nephrectomy in abdominal transplant surgery fellowship.

BACKGROUND: An increasing number of transplant centers have adopted robot-assisted living donor nephrectomy. Thus, a transplant fellow assessment tool is needed for promoting operative independence in an objective and safe manner. METHODS: In this pilot study, data was prospectively collected on both fellow performance with focus on technique, efficiency, and communication ("overall RO-SCORE"), and operative steps ("operative steps RO-SCORE"). Robotic user performance metrics were analyzed from the da Vinci Xi system, including fellow percent active control time (ACT) and handoff counts. RESULTS: From July 2020 to February 2021, twenty-one robot-assisted donor nephrectomies were performed. In regression analysis, fellow performance (based on both RO-SCOREs and robot % ACT) was significantly associated with both time and case number, with time-to-independence modelled at 8.4-14.2 months, and case number-to-independence estimated at 15-22 cases. Robot user metrics provided valid objective measures alongside RO-SCOREs. CONCLUSIONS: This pilot study provides an effective assessment tool for promoting operative competency in robot-assisted donor nephrectomy among transplant fellows.

Clinical Utility of a Hand-Held Scanner for Breast Cancer Early Detection and Patient Triage.

PURPOSE: Globally, breast cancer represents the most common cause of cancer death among women. Early cancer diagnosis is difficult in low- and middle-income countries, most of which are unable to support population-based mammographic screening. Triage on the basis of clinical breast examination (CBE) alone can be difficult to implement. In contrast, piezo-electric palpation (intelligent Breast Exam [iBE]) may improve triage because it is portable, low cost, has a short learning curve, and provides electronic documentation for additional diagnostic workup. We compared iBE and CBE performance in a screening patient cohort from a Western mammography center. METHODS: Women presenting for screening or diagnostic workup were enrolled and underwent iBE then CBE, followed by mammography. Mammography was classified as negative (BI-RADS 1 or 2) or positive (BI-RADS 3, 4, or 5). Measures of accuracy and κ score were calculated. RESULTS: Between April 2015 and May 2017, 516 women were enrolled. Of these patients, 486 completed iBE, CBE, and mammography. There were 101 positive iBE results, 66 positive CBE results, and 35 positive mammograms. iBE and CBE demonstrated moderate agreement on categorization (κ = 0.53), but minimal agreement with mammography (κ = 0.08). iBE had a specificity of 80.3% and a negative predictive value of 94%. In this cohort, only five of 486 patients had a malignancy; iBE and CBE identified three of these five. The two cancers missed by both modalities were small-a 3-mm retro-areolar and a 1-cm axillary tail. CONCLUSION: iBE performs comparably to CBE as a triage tool. Only minimal cancers detected through mammographic screening were missed on iBE. Ultimately, our data suggest that iBE and CBE can synergize as triage tools to significantly reduce the numbers of patients who need additional diagnostic imaging in resource-limited areas.