A Multicenter Analysis of the Early Impact of COVID-19 on Junior Resident Operative Case Volume.

INTRODUCTION: Institutions have reported decreases in operative volume due to COVID-19. Junior residents have fewer opportunities for operative experience and COVID-19 further jeopardizes their operative exposure. This study quantifies the impact of the COVID-19 pandemic on resident operative exposure using resident case logs focusing on junior residents and categorizes the response of surgical residency programs to the COVID-19 pandemic. MATERIALS AND METHODS: A retrospective multicenter cohort study was conducted; 276,481 case logs were collected from 407 general surgery residents of 18 participating institutions, spanning 2016-2020. Characteristics of each institution and program changes in response to COVID-19 were collected via surveys. RESULTS: Senior residents performed 117 more cases than junior residents each year (P < 0.001). Prior to the pandemic, senior resident case volume increased each year (38 per year, 95% confidence interval 2.9-74.9) while junior resident case volume remained stagnant (95% confidence interval 13.7-22.0). Early in the COVID-19 pandemic, junior residents reported on average 11% fewer cases when compared to the three prior academic years (P = 0.001). The largest decreases in cases were those with higher resident autonomy (Surgeon Jr, P = 0.03). The greatest impact of COVID-19 on junior resident case volume was in community-based medical centers (246 prepandemic versus 216 during pandemic, P = 0.009) and institutions which reached Stage 3 Program Pandemic Status (P = 0.01). CONCLUSIONS: Residents reported a significant decrease in operative volume during the 2019 academic year, disproportionately impacting junior residents. The long-term consequences of COVID-19 on junior surgical trainee competence and ability to reach cases requirements are yet unknown but are unlikely to be negligible.

Beyond the Surgical Time-Out: A National Needs Assessment of Preoperative Communication in US General Surgery Residency Programs.

OBJECTIVE: Perioperative communication is critical for procedural learning. In order to develop a periprocedural faculty development tool, we aimed to characterize the current status of preoperative communication in US General Surgery residency programs. DESIGN: After Association of Program Directors in Surgery approval, a survey was distributed to general surgery programs. Participants were asked about perioperative communication, including the frequency of preoperative briefings, defined as dedicated educational discussions prior to a procedure. Data were analyzed using descriptive statistics. SETTING: An anonymous electronic survey was distributed to interested programs in early 2019. PARTICIPANTS: US General Surgery trainees and attending surgeons. RESULTS: A total of 348 responses were recorded from 27 programs: 199 (57%) attending surgeons and 149 (43%) surgical trainees. Most respondents (83%) were from a university-affiliated program. Attending surgeons indicated a higher frequency of performing preoperative briefings compared to trainees (p < 0.001). Both trainees and attending surgeons were more likely to select their own group when asked who initiates a preoperative briefing. The majority of respondents (58%) agreed that discussing autonomy preoperatively improves resident autonomy for the case. In regards to the timing of preoperative briefings, most took place in/adjacent to the operating room, with only 60 participants (17%) participating in preoperative briefings the day/night prior to the operation. The most frequent topic discussed during preoperative briefings was "procedural content." Most participants selected "time constraints" as the greatest barrier to preoperative briefings and indicated that attending surgeon engagement was necessary to facilitate their use. Trainees were less likely to report engaging in immediate postoperative feedback, but more likely to report postoperative self-reflection. CONCLUSIONS: Preoperative briefings are not necessarily routine and attendings and trainees differ on their perceptions related to their content and frequency. Efforts to address timing and scheduling and encourage dual-party engagement in perioperative communication are key to the development of tools to enhance this important aspect of procedural learning.

Association Between Entrustable Professional Activities and Milestones Evaluations: Real-time Assessments Correlate With Semiannual Reviews.

OBJECTIVE: Entrustable professional activities (EPAs) have been developed to refine competency-based education. The American Board of Surgery has initiated a 2-year pilot study to evaluate the impact of EPAs on the evaluation and feedback of surgical residents. The ACGME Milestones in Surgery is a semiannual competency-based evaluation program to measure resident progression through 16 professional attributes across 8 practice domains. The correlation between these 2 evaluation tools remains unclear. The purpose of this study is to evaluate this correlation through comparison of an EPA with the corresponding elements of the ACGME Milestones. DESIGN: From July, 2018 to October, 2019, all residents submitting EPA evaluations for gall bladder disease were evaluated for preoperative, intraoperative, and/or postoperative entrustability. The ratings were converted to a numerical rank from 0 to 4. Milestones scores from May 2019 and November 2019 were obtained for each resident, with scores ranging from 0 to 4. The gall bladder EPA incorporates the operative PC3 and MK2 and nonoperative PC1, PC2, and ICS3 components. Spearman rank correlation was conducted to evaluate the association between each resident's median EPA ranking and his/her milestones scores. SETTING: SUNY Upstate Medical University, Syracuse, NY, a university-based hospital. PARTICIPANTS: General surgery residents. RESULTS: Among 24 residents, 106 intraoperative EPA evaluations were. For both the May and November milestones, significant positive correlations were noted for PC3 (correlation coefficient ρ = 0.690, p < 0.001; ρ = 0.876, p < 0.001). Similarly, for MK2, a significant positive correlation was noted (ρ = 0.882, p < 0.001; ρ = 0.759, p < 0.001). Interestingly, significant positive correlations were also identified between the 3 nonoperative milestones and the intraoperative entrustability ranking. CONCLUSIONS: We observed significant correlations between EPAs for cholecystectomy and associated milestones evaluation scores. These findings indicate that EPAs may provide more timely and specific feedback than existing tools and, on aggregate, may improve upon existing formative feedback practices provided through the biannual evaluation of surgical residents.

Concordance Between Expert and Nonexpert Ratings of Condensed Video-Based Trainee Operative Performance Assessment.

OBJECTIVE: We examined the impact of video editing and rater expertise in surgical resident evaluation on operative performance ratings of surgical trainees. DESIGN: Randomized independent review of intraoperative video. SETTING: Operative video was captured at a single, tertiary hospital in Boston, MA. PARTICIPANTS: Six common general surgery procedures were video recorded of 6 attending-trainee dyads. Full-length and condensed versions (n = 12 videos) were then reviewed by 13 independent surgeon raters (5 evaluation experts, 8 nonexperts) using a crossed design. Trainee performance was rated using the Operative Performance Rating Scale, System for Improving and Measuring Procedural Learning (SIMPL) Performance scale, the Zwisch scale, and ten Cate scale. These ratings were then standardized before being compared using Bayesian mixed models with raters and videos treated as random effects. RESULTS: Editing had no effect on the Operative Performance Rating Scale Overall Performance (-0.10, p = 0.30), SIMPL Performance (0.13, p = 0.71), Zwisch (-0.12, p = 0.27), and ten Cate scale (-0.13, p = 0.29). Additionally, rater expertise (evaluation expert vs. nonexpert) had no effect on the same scales (-0.16 (p = 0.32), 0.18 (p = 0.74), 0.25 (p = 0.81), and 0.25 (p = 0.17). CONCLUSIONS: There is little difference in operative performance assessment scores when raters use condensed videos or when raters who are not experts in surgical resident evaluation are used. Future validation studies of operative performance assessment scales may be facilitated by using nonexpert surgeon raters viewing videos condensed using a standardized protocol.

A systematic review and meta-analysis of predictors of recurrence in patients with Solid Pseudopapillary Tumors of the Pancreas.

BACKGROUND: The recurrence rates and predictors of recurrence in patients with Solid Pseudopapillary tumors (SPT) are unclear, which makes it challenging to determine the duration of follow-up. The aim of the current study was to perform a systematic review and meta-analysis to determine the recurrence rates and pathologic factors associated with recurrence in patients with SPT. METHODS: A PubMed, Scopus, and Web of Science search was conducted to identify studies of SPT published during the last 15 years: (09/2002-09/2017). Studies reporting on patients with SPT and follow-up of >5 years were included. The search strategy was conducted per 2009 PRISMA guidelines. RESULTS: A total of 103 studies reporting on 2599 non-metastatic SPT patients were identified. Sixty-nine patients (2.6%) developed recurrence during follow-up. Pooled estimates from studies with a sample size >20 (N = 33) noted an overall recurrence rate of 2% (95% CI 1-2%). Male gender (OR 1.960), positive lymph nodes (OR 11.9), R1 margins (OR 11.1), and LVI (OR 5.5), were associated with a significantly (all p < 0.05) increased risk of recurrence. CONCLUSION: Current meta-analysis suggests that only 2% of patients with SPT experience recurrence after resection. These data will guide the treating physicians and patients regarding recurrence rates and help identify patients at increased risk of recurrence during follow-up.

The effect of gender on operative autonomy in general surgery residents.

BACKGROUND: Despite an increasing number of women in the field of surgery, bias regarding cognitive or technical ability may continue to affect the experience of female trainees differently than their male counterparts. This study examines the differences in the degree of operative autonomy given to female compared with male general surgery trainees. METHODS: A smartphone app was used to collect evaluations of operative autonomy measured using the 4-point Zwisch scale, which describes defined steps in the progression from novice ("show and tell") to autonomous surgeon ("supervision only"). Differences in autonomy between male and female residents were compared using hierarchical logistic regression analysis. RESULTS: A total of 412 residents and 524 faculty from 14 general surgery training programs evaluated 8,900 cases over a 9-month period. Female residents received less autonomy from faculty than did male residents overall (P < .001). Resident level of training and case complexity were the strongest predictors of autonomy. Even after controlling for potential confounding factors, including level of training, intrinsic procedural difficulty, patient-related case complexity, faculty sex, and training program environment, female residents still received less operative autonomy than their male counterparts. The greatest discrepancy was in the fourth year of training. CONCLUSION: There is a sex-based difference in the autonomy granted to general surgery trainees. This gender gap may affect female residents' experience in training and possibly their preparation for practice. Strategies need to be developed to help faculty and residents work together to overcome this gender gap.

Is the operative autonomy granted to a resident consistent with operative performance quality.

BACKGROUND: We investigated attending surgeon decisions regarding resident operative autonomy, including situations where operative autonomy was discordant with performance quality. METHODS: Attending surgeons assessed operative performance and documented operative autonomy granted to residents from 14 general surgery residency programs. Concordance between performance and autonomy was defined as "practice ready performance/meaningfully autonomous" or "not practice ready/not meaningfully autonomous." Discordant circumstances were practice ready/not meaningfully autonomous or not practice ready/meaningfully autonomous. Resident training level, patient-related case complexity, procedure complexity, and procedure commonality were investigated to determine impact on autonomy. RESULTS: A total of 8,798 assessments were collected from 429 unique surgeons assessing 496 unique residents. Practice-ready and exceptional performances were 20 times more likely to be performed under meaningfully autonomous conditions than were other performances. Meaningful autonomy occurred most often with high-volume, easy and common cases, and less complex procedures. Eighty percent of assessments were concordant (38% practice ready/meaningfully autonomous and 42% not practice ready/not meaningfully autonomous). Most discordant assessments (13.8%) were not practice ready/meaningfully autonomous. For fifth-year residents, practice ready/not meaningfully autonomous ratings (9.7%) were more frequent than not practice ready/meaningfully autonomous ratings (7.5%). Ten surgeons (2.3%) failed to afford residents meaningful autonomy on any occasion. CONCLUSION: Resident operative performance quality is the most important determinant in attending surgeon decisions regarding resident autonomy.

Readiness of US General Surgery Residents for Independent Practice.

OBJECTIVE: This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. BACKGROUND: The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. METHODS: Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. RESULTS: A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%. CONCLUSIONS: US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Limiting ventilator-associated lung injury in a preterm porcine neonatal model.

PURPOSE: Preterm infants are prone to respiratory distress syndrome (RDS), with severe cases requiring mechanical ventilation for support. However, there are no clear guidelines regarding the optimal ventilation strategy. We hypothesized that airway pressure release ventilation (APRV) would mitigate lung injury in a preterm porcine neonatal model. METHODS: Preterm piglets were delivered on gestational day 98 (85% of 115day term), instrumented, and randomized to volume guarantee (VG; n=10) with low tidal volumes (5.5cm3kg-1) and PEEP 4cmH2O or APRV (n=10) with initial ventilator settings: PHigh 18cmH2O, PLow 0cmH2O, THigh 1.30s, TLow 0.15s. Ventilator setting changes were made in response to clinical parameters in both groups. Animals were monitored continuously for 24hours. RESULTS: The mortality rates between the two groups were not significantly different (p>0.05). The VG group had relatively increased oxygen requirements (FiO2 50%±9%) compared with the APRV group (FiO2 28%±5%; p>0.05) and a decrease in PaO2/FiO2 ratio (VG 162±33mmHg; APRV 251±45mmHg; p<0.05). The compliance of the VG group (0.51±0.07L·cmH2O-1) was significantly less than the APRV group (0.90±0.06L·cmH2O-1; p<0.05). CONCLUSION: This study demonstrates that APRV improves oxygenation and compliance as compared with VG. This preliminary work suggests further study into the clinical uses of APRV in the neonate is warranted. LEVEL OF EVIDENCE: Not Applicable (Basic Science Animal Study).

The Feasibility of Real-Time Intraoperative Performance Assessment With SIMPL (System for Improving and Measuring Procedural Learning): Early Experience From a Multi-institutional Trial.

PURPOSE: Intraoperative performance assessment of residents is of growing interest to trainees, faculty, and accreditors. Current approaches to collect such assessments are limited by low participation rates and long delays between procedure and evaluation. We deployed an innovative, smartphone-based tool, SIMPL (System for Improving and Measuring Procedural Learning), to make real-time intraoperative performance assessment feasible for every case in which surgical trainees participate, and hypothesized that SIMPL could be feasibly integrated into surgical training programs. METHODS: Between September 1, 2015 and February 29, 2016, 15 U.S. general surgery residency programs were enrolled in an institutional review board-approved trial. SIMPL was made available after 70% of faculty and residents completed a 1-hour training session. Descriptive and univariate statistics analyzed multiple dimensions of feasibility, including training rates, volume of assessments, response rates/times, and dictation rates. The 20 most active residents and attendings were evaluated in greater detail. RESULTS: A total of 90% of eligible users (1267/1412) completed training. Further, 13/15 programs began using SIMPL. Totally, 6024 assessments were completed by 254 categorical general surgery residents (n = 3555 assessments) and 259 attendings (n = 2469 assessments), and 3762 unique operations were assessed. There was significant heterogeneity in participation within and between programs. Mean percentage (range) of users who completed ≥1, 5, and 20 assessments were 62% (21%-96%), 34% (5%-75%), and 10% (0%-32%) across all programs, and 96%, 75%, and 32% in the most active program. Overall, response rate was 70%, dictation rate was 24%, and mean response time was 12 hours. Assessments increased from 357 (September 2015) to 1146 (February 2016). The 20 most active residents each received mean 46 assessments by 10 attendings for 20 different procedures. CONCLUSIONS: SIMPL can be feasibly integrated into surgical training programs to enhance the frequency and timeliness of intraoperative performance assessment. We believe SIMPL could help facilitate a national competency-based surgical training system, although local and systemic challenges still need to be addressed.

Using the ACGME Milestones for Resident Self-Evaluation and Faculty Engagement.

BACKGROUND: Since July 2014 General Surgery residency programs have been required to use the Accreditation Council for Graduate Medical Education milestones twice annually to assess the progress of their trainees. We felt this change was a great opportunity to use this new evaluation tool for resident self-assessment and to furthermore engage the faculty in the educational efforts of the program. METHODS: We piloted the milestones with postgraduate year (PGY) II and IV residents during the 2013/2014 academic year to get faculty and residents acquainted with the instrument. In July 2014, we implemented the same protocol for all residents. Residents meet with their advisers quarterly. Two of these meetings are used for milestones assessment. The residents perform an independent self-evaluation and the adviser grades them independently. They discuss the evaluations focusing mainly on areas of greatest disagreement. The faculty member then presents the resident to the clinical competency committee (CCC) and the committee decides on the final scores and submits them to the Accreditation Council for Graduate Medical Education website. We stored all records anonymously in a MySQL database. We used Anova with Tukey post hoc analysis to evaluate differences between groups. We used intraclass correlation coefficients and Krippendorff's α to assess interrater reliability. RESULTS: We analyzed evaluations for 44 residents. We created scale scores across all Likert items for each evaluation. We compared score differences by PGY level and raters (self, adviser, and CCC). We found highly significant increases of scores between most PGY levels (p < 0.05). There were no significant score differences per PGY level between the raters. The interrater reliability for the total score and 6 competency domains was very high (ICC: 0.87-0.98 and α: 0.84-0.97). Even though this milestone evaluation process added additional work for residents and faculty we had very good participation (93.9% by residents and 92.9% by faculty) and feedback was generally positive. CONCLUSION: Even though implementation of the milestones has added additional work for general surgery residency programs, it has also opened opportunities to furthermore engage the residents in reflection and self-evaluation and to create additional venues for faculty to get involved with the educational process within the residency program. Using the adviser as the initial rater seems to correlate closely with the final CCC assessment. Self-evaluation by the resident is a requirement by the RRC and the milestones seem to be a good instrument to use for this purpose. Our early assessment suggests the milestones provide a useful instrument to track trainee progression through their residency.

The impact of brief team communication, leadership and team behavior training on ad hoc team performance in trauma care settings.

BACKGROUND: Communication breakdowns and care coordination problems often cause preventable adverse patient care events, which can be especially acute in the trauma setting, in which ad hoc teams have little time for advanced planning. Existing teamwork curricula do not address the particular issues associated with ad hoc emergency teams providing trauma care. METHODS: Ad hoc trauma teams completed a preinstruction simulated trauma encounter and were provided with instruction on appropriate team behaviors and team communication. Teams completed a postinstruction simulated trauma encounter immediately afterward and 3 weeks later, then completed a questionnaire. Blinded raters rated videotapes of the simulations. RESULTS: Participants expressed high levels of satisfaction and intent to change practice after the intervention. Participants changed teamwork and communication behavior on the posttest, and changes were sustained after a 3-week interval, though there was some loss of retention. CONCLUSIONS: Brief training exercises can change teamwork and communication behaviors on ad hoc trauma teams.

Endoscopic management of a duodenal duplication cyst.

Gastrointestinal duplications are rare congenital anomalies. Five percent to 10% of them are found in the duodenum. Traditionally, these lesions are treated surgically using either a laparoscopic or open transduodenal approach. We present the successful endoscopic treatment of a symptomatic duodenal duplication cyst in a 9-year-old girl.

A surgical simulation curriculum for senior medical students based on TeamSTEPPS.

OBJECTIVE: To investigate whether the existing Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) curriculum can effectively teach senior medical students team skills. DESIGN Single-group preintervention and postintervention study. SETTING AND INTERVENTION: We integrated a TeamSTEPPS module into our existing resident readiness elective. The curriculum included interactive didactic sessions, discussion groups, role-plays, and videotaped immersive simulation scenarios. MAIN OUTCOME MEASURES: Improvement of self-assessment scores, multiple-choice examination scores, and performance ratings of videotaped simulation scenarios before and after intervention. The videos were rated by masked reviewers on the basis of a global rating instrument (TeamSTEPPS) and a more detailed nontechnical skills evaluation tool(NOTECHS). PARTICIPANTS: Seventeen students participated and completed the study. RESULTS: The self-evaluation scores improved from 12.76 to 16.06 (P < .001). The increase was significant for all of the TeamSTEPPS competencies and highest for leadership skills (from 2.2 to 3.2; P < .001). The multiple-choice score rose from 84.9% to 94.1% (P < .01). The postintervention video ratings were significantly higher for both instruments (TeamSTEPPS, from 2.99 to 3.56; P < .01; and NOTECHS, from 4.07 to 4.59; P < .001). CONCLUSIONS: The curriculum led to improved self-evaluation and multiple-choice scores as well as improved team skills during simulated immersive patient encounters. The TeamSTEPPS framework may be suitable for teaching medical students teamwork concepts and improving their competencies. Larger studies using this framework should be considered to further evaluate the generalizability of our results and the effectiveness of TeamSTEPPS for medical students.

Engaging medical students in the feedback process.

BACKGROUND: There are potential advantages to engaging medical students in the feedback process, but efforts to do so have yielded mixed results. The purpose of this study was to evaluate a student-focused feedback instructional session in an experimental setting. METHODS: Medical students were assigned randomly to either the intervention or control groups and then assigned randomly to receive either feedback or compliments. Tests of knowledge, skills, and attitudes were given before and after the intervention. RESULTS: There was a significant gain of knowledge and skill in the group that received instruction. Satisfaction was higher after compliments in the control group but higher after feedback in the instructional group. There was no change in the subject's willingness to seek feedback. CONCLUSIONS: A student-focused component should be carefully included as part of an overall effort to improve feedback in surgical education. The role of medical student attitudes about feedback requires further investigation.

Team training for surgical trainees.

Healthcare professionals work in teams but are rarely trained together. Realizing the adverse impact of poor teamwork on patient care, the Accreditation Council for Graduate Medical Education requires surgical trainees to demonstrate a mastery of teamwork-related competencies. A number of team training curricula are available in the USA, the best known of which is TeamSTEPPS - developed by the U.S. Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality.

Verification of proficiency in basic skills for postgraduate year 1 residents.

BACKGROUND: The American College of Surgeons and Association of Program Directors in Surgery Phase 1 curriculum involves basic surgical skills instructional modules and Verification of Proficiency. This article is a study and revision of beta versions of the Verification of Proficiency instruments. METHODS: Postgraduate year 1 residents were tested on 11 skills after undergoing lab instruction and practice. Deidentified videotaped performances were scored and data were analyzed to identify correlations between individual checklist items and failure. RESULTS: In all, 23 residents underwent Verification of Proficiency over 2 years; 8 (35%) passed all Verification of Proficiency examinations at the first attempt, 15 (65%) failed at least 1 module, and 11 (48%) failed at least 2 modules. Residents who failed to demonstrate proficiency underwent mandatory remediation and retested until their scores were considered proficient. Scrutiny of the results revealed checklist items that were predictive independently of overall failure. The pass rate was significantly greater in 2009 compared with 2008 after the introduction of rater training and consequences for failure. CONCLUSION: Verification of Proficiency provides a framework to evaluate learner progress toward skills proficiency. That we achieved 100% faculty compliance with more than 250 performances speaks to the feasibility of Verification of Proficiency. This approach should facilitate a more widespread Verification of Proficiency acceptance as a step closer to developing a final proficiency examination for basic surgical skills in postgraduate year 1 residents.

Running a surgical education center: from small to large.

In the last 2 decades, surgical education has experienced a transformative paradigm shift from the purely service-based Halstedian system to a curriculum-driven model based on educational theory. With the advent of minimally invasive surgery and its educational challenges, fostered by the simultaneously occurring rapid advances of computer technology and graphics and further promoted by rising concerns about patient safety, simulation and skills training has become a well-established tool in the arsenal of the surgical educator. Although most training institutions now have access to skills laboratories and simulation centers, running and integrating these facilities into the surgical curriculum remains a challenge. This article outlines general principles that are relevant for training facilities of all sizes and covers aspects from the initial phase of planning and establishing the center until its ultimately successful integration into the surgical education program.