Training in Bariatric Surgery: a National Survey of German Bariatric Surgeons.

INTRODUCTION: Skill in bariatric surgery has been associated with postoperative outcome. Appropriate surgical training is of paramount importance. In order to continuously improve training strategies, it is necessary to assess current practices. AIM: To determine how German bariatric surgeons have been trained and to assess current training strategies. METHODS: Between February 2017 and March 2017, an online census of surgeons registered as members of the German Society for Bariatric and Metabolic Surgery was conducted. A total of three reminders were sent out. Data were analyzed using descriptive statistics. Data was reported as median (interquartile range); percentages were adjusted for completed answers only. RESULTS: A response rate of 51% (n = 214) was achieved. Surgeons reported a median of 14.5 (8-20) years of surgical experience after initial training, with a specific bariatric experience of 7 (4-13) years. The total cumulative bariatric case volume was 240 (80-500) cases, with an annual case volume of 50 (25-80). The most commonly applied approaches to bariatric skills acquisition were "learning by doing" (71%), "course participation" (70%) and "observerships" (70%). Fellowships and the use of operating videos were less frequently applied strategies (19%/ 47%). Interestingly, observerships (94%) and course participation (89%) were rated as very important/important, whereas "learning by doing" (62%), watching operation videos (59%), and fellowships (48%) were less frequently perceived as important/very important training strategies. CONCLUSIONS: The majority of surgeons performing bariatric cases were senior surgeons with more than 10 years of post-training experience; nevertheless, the survey revealed a lack of structured approaches to bariatric specialization training.

Targeted surgical coaching can improve operative self-assessment ability: A single-blinded nonrandomized trial.

BACKGROUND: The aim of the study was to investigate the effect of targeted surgical coaching on self-assessment of laparoscopic operative skill. Accurate self-assessment is vital for autonomous professional development. Surgical coaching can be used for performance improvement, but its role in this domain has been insufficiently investigated. METHODS: This was a single site, nonrandomized, interrupted time series design trial. Participants were residents, fellows, and attending surgeons regularly performing laparoscopic general surgery operations. Each participant was enrolled in an individualized coaching program using review of personal and peer laparoscopic videos. The program involved 3 to 5 sessions over a period of 6 to 19 weeks. Coaching used case debriefing to target self-assessment proficiency, with a focus on objective interpretation of observations and facilitative capacity building. The primary outcome measure was self-assessment accuracy and correlation to expert ratings. The Objective Structured Assessment of Technical Skill global rating scale was utilized for evaluation. RESULTS: Twelve participants were recruited and completed the coaching program. At baseline, there was no correlation between self-assessment and expert ratings. After completion of the coaching program there was correlation between self-assessment and expert ratings (P = .003) and improved self-assessment accuracy compared to baseline (P = .041). CONCLUSION: This study has demonstrated that targeted coaching using video review of laparoscopic cases can improve operative self-assessment accuracy using the Objective Structured Assessment of Technical Skill.

Comprehensive simulation-enhanced training curriculum for an advanced minimally invasive procedure: a randomized controlled trial.

BACKGROUND: There is no comprehensive simulation-enhanced training curriculum to address cognitive, psychomotor, and nontechnical skills for an advanced minimally invasive procedure. OBJECTIVES: 1) To develop and provide evidence of validity for a comprehensive simulation-enhanced training (SET) curriculum for an advanced minimally invasive procedure; (2) to demonstrate transfer of acquired psychomotor skills from a simulation laboratory to live porcine model; and (3) to compare training outcomes of SET curriculum group and chief resident group. SETTING: University. METHODS: This prospective single-blinded, randomized, controlled trial allocated 20 intermediate-level surgery residents to receive either conventional training (control) or SET curriculum training (intervention). The SET curriculum consisted of cognitive, psychomotor, and nontechnical training modules. Psychomotor skills in a live anesthetized porcine model in the OR was the primary outcome. Knowledge of advanced minimally invasive and bariatric surgery and nontechnical skills in a simulated OR crisis scenario were the secondary outcomes. Residents in the SET curriculum group went on to perform a laparoscopic jejunojejunostomy in the OR. Cognitive, psychomotor, and nontechnical skills of SET curriculum group were also compared to a group of 12 chief surgery residents. RESULTS: SET curriculum group demonstrated superior psychomotor skills in a live porcine model (56 [47-62] versus 44 [38-53], P<.05) and superior nontechnical skills (41 [38-45] versus 31 [24-40], P<.01) compared with conventional training group. SET curriculum group and conventional training group demonstrated equivalent knowledge (14 [12-15] versus 13 [11-15], P = 0.47). SET curriculum group demonstrated equivalent psychomotor skills in the live porcine model and in the OR in a human patient (56 [47-62] versus 63 [61-68]; P = .21). SET curriculum group demonstrated inferior knowledge (13 [11-15] versus 16 [14-16]; P<.05), equivalent psychomotor skill (63 [61-68] versus 68 [62-74]; P = .50), and superior nontechnical skills (41 [38-45] versus 34 [27-35], P<.01) compared with chief resident group. CONCLUSION: Completion of the SET curriculum resulted in superior training outcomes, compared with conventional surgery training. Implementation of the SET curriculum can standardize training for an advanced minimally invasive procedure and can ensure that comprehensive proficiency milestones are met before exposure to patient care.

Setting Performance Standards for Technical and Nontechnical Competence in General Surgery.

OBJECTIVES: The objectives of this study were to (1) create a technical and nontechnical performance standard for the laparoscopic cholecystectomy, (2) assess the classification accuracy and (3) credibility of these standards, (4) determine a trainees' ability to meet both standards concurrently, and (5) delineate factors that predict standard acquisition. BACKGROUND: Scores on performance assessments are difficult to interpret in the absence of established standards. METHODS: Trained raters observed General Surgery residents performing laparoscopic cholecystectomies using the Objective Structured Assessment of Technical Skill (OSATS) and the Objective Structured Assessment of Non-Technical Skills (OSANTS) instruments, while as also providing a global competent/noncompetent decision for each performance. The global decision was used to divide the trainees into 2 contrasting groups and the OSATS or OSANTS scores were graphed per group to determine the performance standard. Parametric statistics were used to determine classification accuracy and concurrent standard acquisition, receiver operator characteristic (ROC) curves were used to delineate predictive factors. RESULTS: Thirty-six trainees were observed 101 times. The technical standard was an OSATS of 21.04/35.00 and the nontechnical standard an OSANTS of 22.49/35.00. Applying these standards, competent/noncompetent trainees could be discriminated in 94% of technical and 95% of nontechnical performances (P < 0.001). A 21% discordance between technically and nontechnically competent trainees was identified (P < 0.001). ROC analysis demonstrated case experience and trainee level were both able to predict achieving the standards with an area under the curve (AUC) between 0.83 and 0.96 (P < 0.001). CONCLUSIONS: The present study presents defensible standards for technical and nontechnical performance. Such standards are imperative to implementing summative assessments into surgical training.

Training in Laparoscopic Gastric Cancer Surgery in the Western World: Current Educational Practices, Challenges, and Potential Opportunities at a Large University Centre.

OBJECTIVE: The purpose of this study was to explore and understand how surgeons distribute tasks during a laparoscopic gastrectomy for gastric cancer in an academic teaching environment. DESIGN: An anonymous, cross-sectional, census survey was used to poll trainees' and staff members' opinions pertaining to laparoscopic gastrectomy. SETTING: Academic and community tertiary teaching hospitals, affiliated with the University of Toronto. PARTICIPANTS: All surgeons, within the Department of General Surgery at the University of Toronto, who practice laparoscopic gastrectomy for gastric cancer, were invited to participate. All general surgery residents, postgraduate year 1-5, minimally invasive surgery and surgical oncology fellows at the University of Toronto were invited to participate. Overall response rate was 74.35% (n = 87/117). RESULTS: The results suggested that trainees do not routinely perform the major operative steps. Trainees agreed with faculty in this regard; however, there was a statistically significant difference in opinions, related to the degree of the perceived active operating of the trainees. There was also a difference in opinion, between trainees and faculty, regarding the common reasons for takeover. CONCLUSIONS: The present survey highlights that current level of active exposure of surgical trainees to laparoscopic gastric surgery might be insufficient. A lack of role clarity may further hinder an optimal educational experience during these cases. Adopting a stepwise approach, with task deconstruction, could optimize training. Additional training modalities may be required to ensure technical proficiency is acquired before independent practice.

Structured Training to Improve Nontechnical Performance of Junior Surgical Residents in the Operating Room: A Randomized Controlled Trial.

OBJECTIVE: The objective of the study was to evaluate the effectiveness of structured training on junior trainees' nontechnical performance in an operating room (OR) environment. BACKGROUND: Nontechnical skills (NTS) have been identified as critical competencies of surgeons in the OR, and regulatory bodies have mandated their integration in postgraduate surgical curricula. Strong evidence supporting the effectiveness of curricular NTS training, however, is lacking. METHODS: Junior surgical residents were randomized to receive either conventional residency training or additional NTS training in a 2-month curriculum. Learning was assessed through a knowledge quiz and an attitudes survey. Nontechnical performance was evaluated by blinded assessment of standardized OR crisis simulations at baseline (BL) and posttraining (PT) using the Nontechnical Skills for Surgeons (NOTSS) and Objective Structured Assessment of Nontechnical Skills (OSANTS) rating systems. Results are reported as median (interquartile ranges). RESULTS: Of 23 participants, 22 completed BL and PT assessments. Groups were equal at BL. At PT, curriculum-trained residents (n = 11) scored higher than conventionally trained residents (n = 11) in knowledge [12 (11-13) vs 8 (6-10), P < 0.001] and attitudes [4.58 (4.37-4.73) vs 4.20 (4.00-4.50), P = 0.008] about NTS. In a simulated OR, nontechnical performance of curriculum-trained residents improved significantly from BL to PT [NOTSS: 10 (7-11) vs 13 (10-15), P = 0.012; OSANTS: 23 (17-28) vs 31 (25-33), P = 0.012] whereas conventionally trained residents did not improve [NOTSS: 10 (10-13) vs 11 (9-14), P = 1.00; OSANTS: 26 (24-32) vs 24 (23-32), P = 0.713]. CONCLUSIONS: The results demonstrate the effectiveness of structured curricular training in improving nontechnical performance in the first year of surgical residency, supporting routine implementation of nontechnical components in postgraduate surgical curricula.

Implementation of an Effective Strategy for Teaching Nontechnical Skills in the Operating Room: A Single-blinded Nonrandomized Trial.

OBJECTIVE: To evaluate the effectiveness of debriefing and feedback on intraoperative nontechnical performance as an instructional strategy in surgical training. BACKGROUND: Regulatory authorities for accreditation in North America have included nontechnical skills such as communication and teamwork in the competencies to be acquired by surgical residents before graduation. Concrete recommendations regarding the training and assessment of these competencies, however, are lacking. METHODS: Nonrandomized, single-blinded study using an interrupted time-series design. Eleven senior surgical residents were observed during routine cases in the operating room (OR) at baseline and post-training. The Non-Technical Skills for Surgeons (NOTSS) rating system was used. Observers were trained in NOTSS and blinded to the study purpose. Independent of the blinded observations, a surgeon educator conducted intraoperative observations, which served as the basis for the structured debriefing and feedback intervention. The intervention was administered to participants after a set of (blinded) baseline observations had been completed. Primary outcome was nontechnical performance in the OR as measured by the NOTSS system. Secondary outcome was perceived utility as assessed by a post-training questionnaire. RESULTS: Twelve senior trainees were recruited, 11 completed the study. Average NOTSS scores improved significantly from 3.2 (SD 0.37) at baseline to 3.5 (SD 0.43) post-training [t(10) = -2.55, P = 0.29]. All participants felt the intervention was useful, and the majority thought that debriefing and feedback on nontechnical skills should be integrated in surgical training. CONCLUSIONS: Debriefing and feedback in the OR may represent an effective strategy to ensure development of nontechnical skills in competency-based education.

Characterising 'near miss' events in complex laparoscopic surgery through video analysis.

BACKGROUND: Root cause analyses of surgical complications are of high importance to ensure surgical quality, but specific details on technical causes often remain unclear. Identifying subclinical intraoperative incidents attributable to technical errors is essential for developing rescue mechanisms to prevent adverse outcomes. OBJECTIVE: Descriptive study to characterise intraoperative technical error-event patterns in successful laparoscopic procedures. METHODS: Events (injuries) identified during prior blinded analyses of 54 unedited recordings of bariatric laparoscopic procedures were subjected to a secondary review to determine the presumed underlying error mechanism. The recordings were obtained from one university-based bariatric collaborative programme, and represented consultant, fellow and shared trainee cases. RESULTS: Sixty-six events were identified in 38 recordings, while 16 videos showed no events. In 25 (66%) of the videos that showed events, additional measures such as haemostasis or suture repair were required. Common identified events were minor bleeding (n=39, 59%), thermal injury to non-target tissue (n=7, 11%), serosal tears (n=6, 9%). Common error mechanisms were 'inadequate use of force/distance (too much)' (n=20, 30%) and 'inadequate visualisation' during grasping/dissecting (n=6, 9%), 'inadequate use of force/distance (too much)' using an energy device (n=6, 9%), or during suturing (n=6, 9%). All events were recognised intraoperatively. CONCLUSIONS: Analysis of successful operations allowed the identification of numerous error-event sequences. Reviewing injury mechanisms can enhance surgeons' understanding of relevant errors. This error awareness may aid surgeons in preparing for cases, help avoid errors and mitigate their consequences. Thus, this approach may impact future surgical education and quality initiatives aimed at reducing surgical risks.

Comprehensive Surgical Coaching Enhances Surgical Skill in the Operating Room: A Randomized Controlled Trial.

OBJECTIVES: The aim of the study was to determine whether individualized coaching improved surgical technical skill in the operating room to a higher degree than current residency training. BACKGROUND: Clinical training in the operating room is a valuable opportunity for surgeons to acquire skill and knowledge; however, it often remains underutilized. Coaching has been successfully used in various industries to enhance performance, but its role in surgery has been insufficiently investigated. METHODS: This randomized controlled trial was conducted at one surgical training program. Trainees undergoing a minimally invasive surgery rotation were randomized to either conventional training (CT) or comprehensive surgical coaching (CSC). CT included ward and operating room duties, and regular departmental teaching sessions. CSC comprised performance analysis, debriefing, feedback, and behavior modeling. Primary outcome measures were technical performance as measured on global and procedure-specific rating scales, and surgical safety parameters, measured by error count. Operative performance was assessed by blinded video analysis of the first and last cases recorded by the participants during their rotation. RESULTS: Twenty residents were randomized and 18 completed the study. At posttraining the CSC group (n = 9) scored significantly higher on a procedure-specific skill scale compared with the CT group (n = 9) [median, 3.90 (interquartile range, 3.68-4.30) vs 3.60 (2.98-3.70), P = 0.017], and made fewer technical errors [10 (7-13) vs 18 (13-21), P = 0.003]. Significant within-group improvements for all skill metrics were only noted in the CSC group. CONCLUSIONS: Comprehensive surgical coaching enhances surgical training and results in skill acquisition superior to conventional training.

Objective structured assessment of nontechnical skills: Reliability of a global rating scale for the in-training assessment in the operating room.

BACKGROUND: Nontechnical skills are critical for patient safety in the operating room (OR). As a result, regulatory bodies for accreditation and certification have mandated the integration of these competencies into postgraduate education. A generally accepted approach to the in-training assessment of nontechnical skills, however, is lacking. The goal of the present study was to develop an evidence-based and reliable tool for the in-training assessment of residents' nontechnical performance in the OR. METHODS: The Objective Structured Assessment of Nontechnical Skills tool was designed as a 5-point global rating scale with descriptive anchors for each item, based on existing evidence-based frameworks of nontechnical skills, as well as resident training requirements. The tool was piloted on scripted videos and refined in an iterative process. The final version was used to rate residents' performance in recorded OR crisis simulations and during live observations in the OR. RESULTS: A total of 37 simulations and 10 live procedures were rated. Interrater agreement was good for total mean scores, both in simulation and in the real OR, with intraclass correlation coefficients >0.90 in all settings for average and single measures. Internal consistency of the scale was high (Cronbach's alpha = 0.80). CONCLUSION: The Objective Structured Assessment of Nontechnical Skills global rating scale was developed as an evidence-based tool for the in-training assessment of residents' nontechnical performance in the OR. Unique descriptive anchors allow for a criterion-referenced assessment of performance. Good reliability was demonstrated in different settings, supporting applications in research and education.

Surgical training: design of a virtual care pathway approach.

BACKGROUND: Both intra- and perioperative care are essential for patients' safety. Training for intraoperative technical skills on simulators and for perioperative care in virtual patients have independently demonstrated educational value, but no training combining these 2 approaches has been designed yet. The aim of this study was to design a pathway approach for training in general surgery. A common disease requiring essential skills was chosen, namely, acute appendicitis. METHODS: Preoperative care training was created using virtual patients presenting with acute right iliac fossa (RIF) pain. A competency-based curriculum for laparoscopic appendectomy (LAPP) was designed on a virtual reality simulator: Novices (<10 LAPP) and experienced surgeons (>100 LAPP) were enrolled to perform 2 virtual LAPP for assessment of validity evidence; novices performed 8 further LAPP for analysis of a learning curve. Finally, postoperative virtual patients were reviewed after LAPP. RESULTS: Four preoperative patient scenarios were designed with different presentations of RIF; not all required operative management. Comments were provided through case progression to allow autonomous practice. Ten novices and 10 experienced surgeons were enrolled for intraoperative training. Time taken (median values) of novices versus experienced surgeons (285 vs 259 seconds; P = .026) and performance score (67% vs 99%; P < .0001) demonstrated evidence for validity, whereas path length did not (916 vs 673 cm; P = .113). Proficiency benchmark criteria were defined for measures with validity evidence. Two postoperative virtual patients were created with an uneventful or complicated outcome. CONCLUSION: A virtual care pathway approach has been designed for acute appendicitis, enabling trainees to follow simulated patients from admission to discharge.

Introduction of a comprehensive training curriculum in laparoscopic surgery for medical students: a randomized trial.

BACKGROUND: First- and second-year medical students have limited exposure to basic surgical skills. An introductory, comprehensive, simulation-based curriculum in basic laparoscopic skills may improve medical students' knowledge and technical and nontechnical skills and may raise their interest in a career in surgery. The purpose of this study was to (1) design a comprehensive, simulation-based training curriculum (STC) aimed to introduce junior medical students to basic laparoscopic skills and (2) compare structured and supervised learning and practice to a self-directed approach. METHODS: Twenty-four, pre-clerkship medical students were allocated randomly to either a supervised (STC) or a self-directed learning and practice (SDL) group. Participants in the STC group received structured training in cognitive, and basic technical and nontechnical domains of laparoscopic surgery, whereas the SDL group was invited to engage in SDL in the same domains. RESULTS: At post-training assessment, basic knowledge about laparoscopic surgery, and attitudes toward nontechnical skills were equivalent between STC and SDL groups. The STC group outperformed (mean ± standard deviation) the SDL group on a peg transfer task (58 ± 13 vs 81 ± 19 seconds; P = .005). Participants in the STC group showed significant within-group improvements in knowledge, technical skill, and in 4 of 5 domains of nontechnical skills, whereas participants in the SDL group showed significant within-group improvement in technical skill and in 1 of 5 domains of nontechnical skills. CONCLUSION: Participation in the STC resulted in significant gains in knowledge, technical skill, and attitudes toward nontechnical skills. Exposure of junior medical students to this curriculum before their clinical rotations is expected to enhance learning, maintain motivation, and increase interest in surgery as a future career.

International consensus on safe techniques and error definitions in laparoscopic surgery.

BACKGROUND: Definitions of errors and poor technique in laparoscopic surgery are lacking in modern clinical practice. As a result, educators often base their teaching on personal experience and individual preferences. The objective of this study was to achieve expert consensus regarding these definitions in order to provide a framework for a standardized approach to teaching safe technique and avoiding common errors in laparoscopic surgery. METHODS: A Delphi survey was conducted with an international panel of experts in laparoscopic surgery. Survey items for definitions and examples of errors and resulting injuries (events) were derived from literature reviews and procedural observations. An online platform was used to administer the survey. Experts were requested to rate their level of agreement regarding survey items on a 5-point Likert-type scale; additional comments were facilitated through free-text entries. Consensus was defined as Cronbach's α > 0.70. Items that were rated ≥ 3 ("somewhat agree") by 75 % or more of the panel were included in the consensus list. The Delphi process was continued until all subsections of the survey met the defined consensus level. RESULTS: Two survey rounds were completed with 33 experts from 12 countries (round 1) and 25 experts from nine countries (round 2). Overall consensus was high for both rounds (α = 0.9). Seventeen definitions and 39 examples of errors and events were included in the final consensus list. CONCLUSIONS: Standardized definitions and examples of technical errors in laparoscopic surgery were established using a consensus-based approach. These definitions can serve as uniform nomenclature and can be used by educators as a reference guide to ensure standardization in surgical training and performance assessment.

Current concepts of team training in surgical residency: a survey of North American program directors.

OBJECTIVES: The purpose of the present survey was to (1) establish the prevalence of Crew Resource Management (CRM)- and team-training interventions among general surgery residency programs of the United States and Canada; (2) to characterize current approaches to training and assessment of nontechnical skills; and (3) to inquire about program directors' (PDs') recommendations for future curricula in graduate medical education. DESIGN: An online questionnaire was developed by the authors and distributed via email to the directors of all accredited general surgery residency programs across the United States and Canada. After 3 email reminders, paper versions were sent to all nonresponders. PARTICIPANTS AND SETTING: PDs of accredited general surgery residency programs in the United States and Canada. RESULTS: One hundred twenty (47%) PDs from the United States and 9 (53%) from Canada responded to the survey. Of all respondents, 32% (n = 40) indicated conducting designated team-training interventions for residents. Three main instructional strategies were identified: combined approaches using simulation and didactic methods (42%, n = 16); predominantly simulation-based approaches (37%, n = 14); and didactic approaches (21%, n = 8). Correspondingly, 83% (n = 93) of respondents recommended a combination of didactic methods and opportunities for practice for future curricula. A high agreement between responding PDs was shown regarding learning objectives for a proposed team-based training curriculum (α = 0.95). CONCLUSIONS: The self-reported prevalence of designated CRM- and team-training interventions among responding surgical residency programs was low. For the design of future curricula, the vast majority of responding PDs advocated for the combination of interactive didactic methods and opportunities for practice.

Teaching nontechnical skills in surgical residency: a systematic review of current approaches and outcomes.

BACKGROUND: A growing body of evidence suggests that nontechnical skills (NTS) of surgeons play an important role in patient safety in the operating room and can be improved through specific training interventions. The need to address communication and interpersonal skills in postgraduate medical education has been emphasized by the respective regulatory bodies for accreditation and certification. The present review had 2 purposes: To provide an overview of current approaches to training and assessment of NTS in surgery and to critically appraise the strength of the evidence supporting their effectiveness. METHODS: A systematic search of the literature (Ovid MEDLINE; PsycINFO; Embase) was conducted using predefined inclusion criteria. The evidence for the main outcome themes was appraised using the GRADE approach. RESULTS: Of the 2,831 identified records, 23 were selected for qualitative synthesis. Four randomized, controlled trials and 19 observational pre-post studies were reviewed. Significant effects of training were shown for the identified outcome themes (patient-centered communication, teamwork, decision making, coping with stress, patient safety and error management). The overall strength of evidence supporting training effects on outcome measures was graded as "moderate" (teamwork), "low" (patient-centered communication, decision making, and coping with stress), and "very low" (patient safety and error management), respectively. CONCLUSION: Training interventions can have positive effects on residents' nontechnical knowledge, skills, and attitudes. Although the overall strength of evidence is moderate at best, recent interventions provide valuable information regarding instructional strategies and methods for training and assessment of NTS in modern surgical curricula.

Development, feasibility, validity, and reliability of a scale for objective assessment of operative performance in laparoscopic gastric bypass surgery.

BACKGROUND: There is no objective scale for assessment of operative skill in laparoscopic gastric bypass (LGBP). The objective of this study was to develop and demonstrate feasibility of use, validity, and reliability of a Bariatric Objective Structured Assessment of Technical Skill (BOSATS) scale. STUDY DESIGN: The BOSATS scale was developed using a hierarchical task analysis (HTA), a Delphi questionnaire, and a panel of international experts in bariatric surgery. The feasibility of use, reliability, and validity of the developed scale were demonstrated by reviewing 52 prospectively collected video recordings of LGBP performed by novice and experienced surgeons. RESULTS: A total of 214 discrete steps were identified in HTA. A total of 12 and 17 panel members completed the first and second round of the Delphi questionnaire, respectively. Consensus among the panel was achieved after the second round (Cronbach's alpha = 0.85). The BOSATS scale demonstrated high inter-rater (intraclass correlation coefficient [ICC] = 0.954; p < 0.001) and test-retest reliability (ICC = 0.99; p < 0.001). Significant differences between BOSATS scores of experienced and novice surgeon groups were noted for the creation of jejunojejunostomy (JJ), gastric pouch, linear stapled gastrojejunostomy (GJ), circular stapled GJ, and hand-sewn GJ. Moderate to high correlations between BOSATS scale and Objective Structured Assessment of Technical Skills Global Rating Scale (OSATS GRS) were seen for JJ (rho = 0.59; p = 0.001), gastric pouch (rho = 0.48; p = 0.0004), linear stapled GJ (rho = 0.70; p = 0.0001), and hand-sewn GJ (rho = 0.96; p < 0.0001). CONCLUSIONS: The BOSATS scale is a feasible to use, reliable, and valid instrument for objective assessment of operative performance in LGBP. Implementation of this scale is expected to facilitate deliberate practice and provide a means for future certification in bariatric surgery.

Defining technical errors in laparoscopic surgery: a systematic review.

BACKGROUND: Technical errors, a distinct subcomponent of surgical proficiency, have a significant impact on patient safety and clinical outcomes. To date, only a few studies have been designed to describe and evaluate these errors. This review was performed to assess technical errors described in laparoscopic surgery. METHODS: A literature search of Medline, Cochrane, EMBASE, and OVID databases (1946-2012, week 14) using the terms "technical/medical error," "technical skill," and "adverse event" in combination with the terms "laparoscopy/laparoscopic surgery" was conducted. English language peer review articles with a description of technical errors were included. Opinion papers, reviews, and articles not addressing laparoscopic surgery were excluded. RESULTS: The search returned 2,282 articles. Application of the inclusion criteria reduced the number of articles to 21. Of these 21 articles, 14 (67 %) were observational studies, 3 (14 %) were randomized trials, 2 (10 %) were prospective interventional studies, and 2 (10 %) were retrospective analyses. Eight articles (38 %) applied error analysis as an approach to determine error rates within routine procedures. The remaining 13 articles (62 %) used the assessment of errors to describe and quantify surgical skill in an educational setting. CONCLUSIONS: A number of approaches for the assessment of surgical technical errors exist. The error definitions vary greatly, making a comparison of error rates between groups impossible. Complexity of scale design and subjectivity in ratings have resulted in limited use of these scores outside the experimental setting. To facilitate error analysis as a self-assessment method of continuous learning and quality control, further research and better tools are required.

Laparoscopic simulation training: does timing impact the quality of skills acquisition?

BACKGROUND: Current surgical training involves integration of educational interventions together with service requirements during regular working hours. Studies have shown that voluntary training has a low acceptance among surgical trainees and obligatory simulation training during the regular working week leads to better skill acquisition and retention. We examined the difference in training effectiveness depending on the time of day. METHODS: Surgical novices underwent a curriculum consisting of nine basic laparoscopic tasks. The subjects were permitted to choose a training session between during regular working hours (8:00-16:00) or after hours (16:00-20:00). Each subject underwent baseline and post-training evaluation after completion of two 4-h sessions. Task completion was measured in time (s), with penalties for inaccurate performance. Statistical analysis included matched-pairs analysis (sex, age, and previous operative experience) with χ(2) und Mann-Whitney U test for between groups and Wilcoxon signed-rank test for testing within one group. RESULTS: There were no differences in demographic characteristics between the groups. Comparison of the individual baseline and post-training performance scores showed a significant (P < 0.05) improvement for all subjects in all exercises. No significant differences between groups were observed. CONCLUSION: All subjects improved in skill significantly throughout the week regardless of the timing of the training intervention. Simulation training can be offered outside of regular working hours with acceptable effectiveness.

Blended learning in surgery using the Inmedea Simulator.

BACKGROUND: Recently, medical education in surgery has experienced several modifications. We have implemented a blended learning module in our teaching curriculum to evaluate its effectiveness, applicability, and acceptance in surgical education. METHODS: In this prospective study, the traditional face-to-face learning of our teaching curriculum for fourth-year medical students (n = 116) was augmented by the Inmedea Simulator, a web-based E-learning system, with six virtual patient cases. Student results were documented by the system and learning success was determined by comparing patient cases with comparable diseases (second and sixth case). The acceptance among the students was evaluated with a questionnaire. RESULTS: After using the Inmedea Simulator, correct diagnoses were found significantly (P < 0.05) more often, while an incomplete diagnostic was seen significantly (P < 0.05) less often. Significant overall improvement (P < 0.05) was seen in sixth case (62.3 ± 5.6 %) vs. second case (53.9 ± 5.6 %). The questionnaire revealed that our students enjoyed the surgical seminar (score 2.1 ± 1.5) and preferred blended learning (score 2.5 ± 1.2) to conventional teaching. CONCLUSION: The blended learning approach using the Inmedea Simulator was highly appreciated by our medical students and resulted in a significant learning success. Blended learning appears to be a suitable tool to complement traditional teaching in surgery.

Laparoscopic simulation training: Testing for skill acquisition and retention.

BACKGROUND: Simulation in laparoscopy leads to skill acquisition. Although many curricula for simulation training have been described, the nature of skill deterioration remains unclear. We evaluated skill acquisition and retention after laparoscopic simulation training. METHODS: Thirty-six novices in surgery (medical students) underwent a 5-day curriculum consisting of 9 skills of increasing complexity. Each subject underwent baseline and post-training evaluation after completion of the course. Skill retention testing was measured after 6 weeks (group 1; n = 18) and after 11 weeks (group 2; n = 18). Neither group had access to a training facility during this interval. Task completion was measured in time (s) with penalties for inaccurate performance. RESULTS: Comparison of the baseline and post-training values revealed a significant learning outcome for all exercises in both groups (P < .001). In group 1, skill retention testing found no significant decrease in skill level when compared to post-training values in all but 1 task (extracorporeal knot tying; P = .007). In group 2, differences between skill retention and post-training evaluation were observed for 5 of the 9 tasks (transfer task, positioning, loop tie, extracorporeal knot, and intracorporeal knot; P ≤ .05 for each). CONCLUSION: Basic laparoscopic skills can be learned successfully by novices in surgery using a compact curriculum. These skills are retained for at least 6 weeks. Eleven weeks after initial training, skill deterioration is likely, and therefore an opportunity for practice and repetition is desirable.