Skill Acquisition, Assessment, and Simulation in Minimal Access Surgery: An Evolution of Technical Training in Surgery.

Diminishing resources and expanding technologies, such as minimal access surgery, have complicated the acquisition and assessment of technical skills in surgical training programs. However, these challenges have been met with both innovation and an evolution in our understanding of how learners develop technical competence and how to better measure it. As these skills continue to grow in breadth and complexity, so too must the surgical education systems' ability. This literature review examines and describes the pressures placed on surgical education programs and the development of methods to ameliorate them with a focus on surgical simulation.

A Preliminary Investigation of General and Technique-specific Assessments for the Evaluation of Laparoscopic Technical Skills.

Background  Both general and technique-specific assessments of technical skill have been validated in surgical education. The purpose of this study was to assess the correlation between the objective structured assessment of technical skills (OSATS) and the global operative assessment of laparoscopic skills (GOALS) rating scales using a high-fidelity porcine laparoscopic cholecystectomy model. Methods Post-graduate year-one general surgery and urology residents (n=14) performed a live laparoscopic porcine cholecystectomy. Trained surgeons rated their performance using OSATS and GOALS assessment scales. Results Pearson's correlation coefficient between OSATS and GOALS was 0.96 for overall scores. It ranged from 0.78 - 0.89 for domains that overlapped between the two scales. Conclusion There is a very high correlation between OSATS and GOALS. This implies that they likely measure similar constructs and that either may be used for summative-type assessments of trainee skill. However, further investigation is needed to determine if technique-specific assessments may provide more useful feedback in formative evaluation.

Establishing the concurrent validity of general and technique-specific skills assessments in surgical education.

BACKGROUND: Laparoscopic surgery entails a unique skill set, but it is unclear whether it requires a specific assessment form or whether more general assessment tools can be applied. The purpose of this study was to assess the concurrent validity of 2 previously validated assessment scales. One scale designed specifically to assess laparoscopic skills and the other to assess more general surgical skills. METHODS: Postgraduate year 1-6 general surgery and urology residents (n = 33) performed a live laparoscopic cholecystectomy. Three surgeon raters scored their performance using previously validated objective structured assessment of technical skills (OSATS) and global operative assessment of laparoscopic skills rating scales. RESULTS: Pearson's correlation coefficient between global operative assessment of laparoscopic skills and OSATS rating scales was .975 (P = .01). CONCLUSIONS: The near total correlation between the 2 scales questions the need for separate laparoscopic assessment tools, highlighting the real strengths of OSATS, the use of which allows for more consistent nomenclature and standardized skills assessment across surgical platforms.

The Fundamentals of Laparoscopic Surgery and LapVR evaluation metrics may not correlate with operative performance in a novice cohort.

BACKGROUND: Considerable resources have been invested in both low- and high-fidelity simulators in surgical training. The purpose of this study was to investigate if the Fundamentals of Laparoscopic Surgery (FLS, low-fidelity box trainer) and LapVR (high-fidelity virtual reality) training systems correlate with operative performance on the Global Operative Assessment of Laparoscopic Skills (GOALS) global rating scale using a porcine cholecystectomy model in a novice surgical group with minimal laparoscopic experience. METHODS: Fourteen postgraduate year 1 surgical residents with minimal laparoscopic experience performed tasks from the FLS program and the LapVR simulator as well as a live porcine laparoscopic cholecystectomy. Performance was evaluated using standardized FLS metrics, automatic computer evaluations, and a validated global rating scale. RESULTS: Overall, FLS score did not show an association with GOALS global rating scale score on the porcine cholecystectomy. None of the five LapVR task scores were significantly associated with GOALS score on the porcine cholecystectomy. CONCLUSIONS: Neither the low-fidelity box trainer or the high-fidelity virtual simulator demonstrated significant correlation with GOALS operative scores. These findings offer caution against the use of these modalities for brief assessments of novice surgical trainees, especially for predictive or selection purposes.

Endoscopy training in Canadian general surgery residency programs.

Currently, general surgeons provide about 50% of endoscopy services across Canada and an even greater proportion outside large urban centres. It is essential that endoscopy remain a core component of general surgery practice and a core competency of general surgery residency training. The Canadian Association of General Surgeons Residents Committee supports the position that quality endoscopy training for all Canadian general surgery residents is in the best interest of the Canadian public. However, the means by which quality endoscopy training is achieved has not been defined at a national level. Endoscopy training in Canadian general surgery residency programs requires standardization across the country and improved measurement to ensure that competency and basic credentialing requirements are met.

Laparoscopic right hemicolectomy with intracorporeal versus extracorporeal anastamosis: a comparison of short-term outcomes.

BACKGROUND: There is wide variation among laparoscopic colon resection techniques, including the approach for mobilization and the extent of intracorporal vessel ligation, bowel division or anastamosis. We compared the short-term outcomes of laparoscopic right hemicolectomy (LRHC) with intracorporeal (IA) versus extracorporeal (EA) anastamosis. METHODS: We retrospectively reviewed all elective laparoscopic right hemicolectomies performed at St. Joseph's Hospital between January 2008 and September 2009 and compared the demographic, pathologic, operative and outcome data. RESULTS: Fifty LRHCs were completed during the study period: 21 IA and 29 EA. The groups were similar in age, sex, body mass index, American Society of Anesthesiologists score, previous laparotomy and preoperative invasive pathology. There was no difference between IA and EA in mean duration of surgery (170 v. 181 min, p = 0.78), estimated blood loss (14 v. 42 mL, p = 0.15), perioperative blood transfusions (5% v. 14%, p = 0.29), in-hospital morbidity (33% v. 41%, p = 0.56), out-of-hospital morbidity (19% v. 31% p = 0.34), emergency department visits (10% v. 17%, p = 0.16) or 30-day readmissions (5% v. 7%, p = 0.75). There was 1 anastamotic leak in each group and no perioperative deaths. Median length of stay was significantly shorter for IA (4 v. 5 d, p = 0.05). There were 6 extraction site hernias with EA and none with IA (p = 0.026). CONCLUSION: Laparoscopic right hemicolectomy with IA has the advantage of a less hernia-prone Pfannenstiel extraction site, faster recovery and shorter stay in hospital EA.

CONTEXTE: Il existe énormément de variations entre les techniques d'exérèse du côlon par laparascopie, y compris en ce qui concerne l'approche adoptée pour la mobilisation et l'étendue de la ligature vasculaire intracorporelle, la séparation du côlon ou l'anastomose. Nous avons comparé les résultats à court terme de l'hémicolectomie droite laparascopique (HDL) avec anastomose intracorporelle (AI) à ceux de l'HDL avec anastomose extracorporelle (AE). MÉTHODES: Nous avons effectué une analyse rétrospective de toutes les hémicolectomies droites laparascopiques non urgentes pratiquées à l'hôpital St. Joseph entre janvier 2008 et septembre 2009, et comparé les données démographiques, pathologiques et opératoires et les données sur les résultats. RÉSULTATS: Cinquante HDL ont été pratiquées au cours de l'étude : 21 avec AI et 29 avec AE. Les groupes de patients étaient comparables pour ce qui était de l'âge, du sexe, de l'indice de masse corporelle, du score de l'American Society of Anesthesiologists, des antécédents de laparatomie et de la pathologie invasive préopératoire. Aucune différence n'a été observée entre l'AI et l'AE pour ce qui est de la durée moyenne de l'intervention chirurgicale (170 c. 181 min, p = 0,78), de la perte de sang estimée (14 c. 42 mL, p = 0,15), des transfusions sanguines péri-opératoires (5 % c. 14 %, p = 0,29), de la morbidité hospitalière (33 % c. à 41 %, p = 0,56), de la morbidité extra-hospitalière (19 % c. 31 %, p = 0,34), des admissions à l'urgence (10 % c. 17 %, p = 0,16) ou des réadmissions à l'hôpital dans les 30 jours (5 % c. 7 %, p = 0,75). On a signalé 1 fuite anastomique dans chaque groupe, mais aucun décès péri-opératoire. La durée médiane de l'hospitalisation était significativement plus courte pour les AI (4 c. 5 j, p = 0,05). Il y a eu 6 hernies au point d'extraction pour les AE, mais aucune pour les AI (p = 0,026). CONCLUSION: L'hémicolectomie droite laparascopique avec AI a l'avantage de réduire le risque d'hernie au point d'extraction après incision de Pfannenstiel, d'accélérer le rétablissement de réduire la durée de l'hospitalisation.

Does laparoscopic simulation predict intraoperative performance? A comparison between the Fundamentals of Laparoscopic Surgery and LapVR evaluation metrics.

BACKGROUND: Considerable resources have been invested in low- and high-fidelity simulators in surgical training. To our knowledge, no investigation has compared the 2 head to head for operative assessment purposes. The purpose of this study was to assess the Fundamentals of Laparoscopic Surgery (FLS) low-fidelity video trainer and LapVR (high-fidelity virtual-reality simulator) for (1) construct and (2) predictive validity using a human cholecystectomy model. METHODS: Twenty-six participants performed tasks from the FLS program and the LapVR simulator as well as a human laparoscopic cholecystectomy. Performance was evaluated using FLS and LapVR metrics and the Objective Structured Assessment of Technical Skills previously validated rating scale. RESULTS: Construct and predictive validity were strongly demonstrated for FLS tasks but only incompletely for LapVR. CONCLUSIONS: Efforts should be focused on using the well-validated lower-cost FLS video trainer for assessment of laparoscopic skills. The high-cost LapVR remains experimental in resource-constrained training programs.

Chlamydophila pneumoniae infection leads to smooth muscle cell proliferation and thickening in the coronary artery without contributions from a host immune response.

Chlamydophila pneumonia (C. pneumonia) infection has been associated with the progression of atherosclerosis. It remains unclear, however, whether C. pneumoniae in the absence of an immune response can alone initiate atherogenic events within a complex vessel environment. Left anterior descending coronary arteries isolated from porcine hearts were dissected and placed in culture medium for 72 hours before infection with C. pneumoniae. C. pneumoniae replicated within the arterial wall for the duration of the experiment (up to 10 days). A significant increase in chlamydial-HSP60 protein expression from day 2 to 10 post-infection (pi) indicated the presence of metabolically active C. pneumonia within infected vessels. Significant arterial thickening in infected coronary segments was observed by a considerable decrease in the ratio of lumen to total vessel area (48 +/- 3% at day 4 pi versus 23 +/- 3% at day 10 pi) and a significant increase in the ratio of media to luminal area (113 +/- 16% at day 4 pi versus 365 +/- 65% at day 10 pi). Structural changes were accompanied by an up-regulation of host HSP60 and proliferating cell nuclear antigen expression levels. Immunohistochemical staining confirmed proliferating cell nuclear antigen expression to be primarily localized within smooth muscle cells of the medial area. These results demonstrate that C. pneumoniae infection can stimulate arterial thickening in a complex vessel environment without the presence of a host immune response and further supports the involvement of HSP60 in this action.