Curriculum Change Needed: A Decline in Antireflux Surgery in the Pediatric Surgery Fellowship.

BACKGROUND: Case number requirements by the Accreditation Council for Graduate Medical Education (ACGME) have recently changed in general surgery residency and pediatric surgery fellowship. Overall, pediatric surgery fellowship case volumes remain high, but there may be limited exposure to many index cases. We hypothesize that pediatric antireflux surgery is decreasing nationally, and this trend is independent of the fluctuating number of pediatric surgery fellows. MATERIALS AND METHODS: A review of publicly available ACGME case reports from 2003 to 2018 was performed. Both open and laparoscopic antireflux surgery cases were evaluated. Analyzed data included average case number per fellow, minimum and maximum case numbers, and number of fellows each year. Simple and multiple linear regression analyses were performed. RESULTS: We identified a significant relationship (P < 0.001) between the total number of antireflux procedures and the years of operation. The slope coefficient was -1.45, meaning the number of operations decreased by an average of 1.45 per year from 2003 to 2018 . The number of fellows fluctuated during this time period (range: 24-45). With multiple linear regression analysis, we found that the number of fellows did not affect the decline of antireflux surgery seen over the years (P = 0.91). CONCLUSIONS: Case numbers continue to be an important topic in ACGME discussions for surgical residency and subspecialty fellowships. Our review has shown a national decline in the number of pediatric antireflux surgeries performed in pediatric surgery fellowship. Identifying additional trends in surgical management of diseases may aid in the evolution of the pediatric surgery curriculum.

A Comparison of the Effectiveness Between Three Different Endoscopic Surgical Skill Training Programs for Medical Students Using the Infant Laparoscopic Fundoplication Simulator: A Randomized Controlled Trial.

Background and Aim: Training programs for developing laparoscopic suturing skills range from dry-box training to virtual simulator training. There are advantages and disadvantages to each training method; however, which training is best for medical students and young surgeons is unclear. The aim of this study was to compare the proficiency of medical students in acquiring laparoscopic suturing skills after various routes of short-term training: via a video, an expert teacher, or a virtual simulator. Materials and Methods: Seventeen medical students were registered and divided randomly into three groups: group receiving personal training while watching a training video (video group), group receiving training under the guidance of an expert (teaching group), and group receiving personal training with a virtual simulator (virtual group). The students practiced laparoscopic suturing and tying skills for 1 hour. Following their training, they performed the evaluation task of three sutures and ties using a laparoscopic fundoplication simulator. We developed a 1-year-old infant body model (body weight 10 kg) based on computed tomography data and established a pneumoperitoneum body model based on a clinical situation. Results: The path length of the assistant forceps in the virtual group tended to be longer than in the other groups. The average acceleration of the assistant forceps in the virtual group was faster than in the other groups (P = .04). There were no significant differences in the other evaluation parameters. Conclusion: A long-term and combination training study should be performed to develop the best method for training medical students and inexperienced young surgeons.

Continuous Skill Training Using the Disease-Specific Endoscopic Surgical Simulator to Promote Young Pediatric Surgeons: Learning Curve for Trainees.

Purpose: This study aimed to evaluate the learning effects of continuous training with a disease-specific endoscopic surgical simulator for young pediatric surgeons. Materials and Methods: Participants trained with a laparoscopic fundoplication simulator for 1 hour every 10 days. At the start of each training session, we assessed the participant's surgical technique using the surgical skill evaluation system, which evaluates the following items: (1) task time, (2) right-left balance of suturing, (3) suture spacing between the three ligatures, (4) total path length traveled by forceps, (5) velocity of the forceps tips, (6) length of the wrap, (7) number of ligature failures, and (8) comparison of improvements according to assessment point. We examined the learning effects of this continuous training program. Results: Task time, right-left balance of suturing, and sum of the distance traveled by each forceps showed significant progressive improvements (P < .05). Suture spacing and average velocity of forceps tips did not change significantly with training (P = .5781, P = .0781, respectively). However, the ratio of traveled distance between left and right forceps significantly improved (P < .05). There was a significant trend for the wrap length to approach the target value (P < .05). According to the linear mixed-effects model, the number of training sessions required for learning was not uniform and varied depending on the skill. Conclusion: This simulator training program can help pediatric surgeons to acquire surgical skills easily, economically, and safely. In the future, we need to evaluate how surgical skills acquired during this continuous training are reflected in clinical operations.

Endosuture trainer box simulator as a tool for training and teaching in bariatric laparoscopic surgery.

BACKGROUND: Video surgery requires acquisition of psychomotor skills that are different from those required for open surgery. The aim of this study was to assess the EndoSuture Trainer Box Simulator (ESTBS), a new bariatric laparoscopic skills simulator, as a tool for surgical education, comparing it with a standard laparoscopic trainer (SLT). METHODS: A randomized prospective crossover study was designed to compare ESTBS versus SLT as a tool for training bariatric laparoscopic skills. Participants were assigned to perform a task simulating Nissen fundoplication operation. All subjects evaluated the simulators concerning to their performance on simulating laparoscopic procedures by the use of a questionnaire comparing: triangulation, resistance and resilience, spatial perception (stereotaxy), ergonomics and positioning, inverted movements, visibility, design, technical and technological resources for training and education. The overall score was defined as the median value obtained. A total of 37 participants were enrolled in the study, including 29 experienced surgeons (78.37%) and 08 surgical residents (21.63%). RESULTS: A superior performance was observed with ESTBS as compared to SLT upon 7 of the 10 items evaluated in the questionnaire. Additionally, the overall score of ESTBS (median of 4, very good) was significantly higher (P < 0.0001) than that of SLT (median of 3, good). For the items, triangulation, resistance and resilience, ergonomics, design, training, technology and teaching, the evaluation for the ESTBS was very good and excellent, which was significantly higher than obtained by SLT. Also, ESTBS was cheaper. CONCLUSIONS: The ESTBS was shown to present excellent technical and technological performances and appears to constitute a useful cost-effective promising instrument for teaching and training bariatric surgical laparoscopic skills.

The impact of the robotic platform on assistant variability in complex gastrointestinal surgery.

BACKGROUND: Nissen fundoplication is considered an advanced minimally invasive procedure whether performed laparoscopically or robotically. In laparoscopic surgery, it is evident that assistant skill level impacts operative times. However, the robotic platform allows improved surgeon autonomy. We aimed to determine the impact of assistant training level on operative times in robotic Nissen fundoplication (RNF) and laparoscopic Nissen fundoplication (LNF). METHODS: A prospectively maintained Nissen database (2011-2016) from a single academic institution was utilized to collect patient characteristics, operative times, length of stay, intraoperative complications, postoperative complications, readmission rate, and assistant training level. Assistants were either postgraduate year-3 surgery residents defined as junior-level assistants or a minimally invasive surgery (MIS) fellow defined as senior-level assistants. RESULTS: There were 105 patients included in our analyses. When comparing postgraduate year-3 residents to MIS fellows performing LNF, the median operative time was significantly decreased when senior-level assistants were present in the LNF group, 85 (75-103) versus 129 (74-269) min, P = 0.02. In comparison, median operative times in the RNF group were independent of the assistant's level of training, 154 (71-300) versus 158 (101-215) min, P = 0.34. There were no significant differences in outcomes between the junior- and senior-level assistant cohorts for estimated blood loss, length of stay, postoperative complications, and 30-d readmission rates in either the LNF or RNF group. CONCLUSIONS: Assistant training level impacted operative time for LNF but not RNF. These differences are most likely attributed to increased autonomy of the operating surgeon afforded by the robotic platform reducing assistant variability.

Simulation Model for Laparoscopic Foregut Surgery: The University of North Carolina Foregut Model.

BACKGROUND: A significant gap presently exists between box-lap and virtual-reality simulators and live surgery. Live animal and cadaver use has significant downsides. We have developed a high fidelity, real tissue simulator that allows training in laparoscopic foregut operations. METHODS: Our foregut surgery model is based on porcine tissue blocks that include lungs, heart, aorta, esophagus, diaphragm, stomach, duodenum, liver, and spleen. The tissue block is mounted in a human mannequin and perfused with artificial blood. The anterior abdominal wall is constructed so as to allow for laparoscopic or robotic surgical training. We sought to test the model with procedures performed by expert surgeons. After completing the procedures, face validity was measured by surgeon responses to a questionnaire defining the perceived relationship to real surgery. RESULTS: Five expert foregut surgeons performed laparoscopic Heller myotomy, Nissen fundoplication, and sleeve gastrectomy on the model. The simulator was rated as highly realistic in terms of tissue feel, instrument usage, and conduct of the operation for all three procedures. In addition, all surgeons felt the model could significantly shorten the learning curve for performing these procedures. CONCLUSIONS: The results of this study show that our simulation model, based on animal tissue blocks, offers a very realistic representation of laparoscopic foregut operations, thus achieving a high level of face validity. The model should be very useful for training surgeons in laparoscopic foregut procedures.

A new innovative laparoscopic fundoplication training simulator with a surgical skill validation system.

PURPOSE: We developed and validated a specific laparoscopic fundoplication simulator for use with the objective endoscopic surgical skills evaluation system. The aim of this study was to verify the quality of skills of surgeons. MATERIALS AND METHODS: We developed a 1-year-old infant body model based on computed tomography data and reproduced pneumoperitoneum model based on the clinical situation. The examinees were divided into three groups: fifteen pediatric surgery experts (PSE), twenty-four pediatric surgery trainees (PSN), and ten general surgeons (GS). They each had to perform three sutures ligatures for construction of Nissen wrap. Evaluate points are time for task, the symmetry of the placement of the sutures, and the uniformity of the interval of suture ligatures in making wrap. And the total path length and velocity of forceps were measured to assess bi-hand coordination. RESULTS: PSE were significantly superior to PSN regarding total time spent (p < 0.01) and total path length (p < 0.01). GS used both forceps faster than the other groups, and PSN used the right forceps faster than the left forceps (p < 0.05). PSE were shorter with regard to the total path length than GS (p < 0.01). PSE showed most excellent results in the symmetry of the wrap among three groups. CONCLUSION: Our new model was used useful to validate the characteristics between GS and pediatric surgeon. Both PSE and GS have excellent bi-hand coordination and can manipulate both forceps equally and had superior skills compared to PSN. In addition, PSE performed most compact and accurate skills in the conflicted operative space.

YouTube as a Potential Training Resource for Laparoscopic Fundoplication.

OBJECTIVE: To analyze the surgical proficiency and educational quality of YouTube videos demonstrating laparoscopic fundoplication (LF). DESIGN: In this cross-sectional study, a search was performed on YouTube for videos demonstrating the LF procedure. The surgical and educational proficiency was evaluated using the objective component rating scale, the educational quality rating score, and total video quality score. Statistical significance was determined by analysis of variance, receiver operating characteristic curve, and odds ratio analysis. RESULTS: A total of 71 videos were included in the study; 28 (39.4%) videos were evaluated as good, 23 (32.4%) were moderate, and 20 (28.2%) were poor. Good-rated videos were significantly longer (good, 22.0 ± 5.2min; moderate, 7.8 ± 0.9min; poor, 8.5 ± 1.0min; p = 0.007) and video duration was predictive of good quality (AUC, 0.672 ± 0.067; 95% CI: 0.541-0.802; p = 0.015). For good quality, the cut-off video duration was 7:42 minute. This cut-off value had a sensitivity of 67.9%, a specificity of 60.5%, and an odds ratio of 3.23 (95% CI: 1.19-8.79; p = 0.022) in predicting good quality. Videos uploaded from industrial sources and with a higher views/days online ratio had a higher objective component rating scale and total video quality score. In contrast, the likes/dislikes ratio was not predictive of video quality. CONCLUSIONS: Many videos showing the LF procedure have been uploaded to YouTube with varying degrees of quality. A process for filtering LF videos with high surgical and educational quality is feasible by evaluating the video duration, uploading source, and the views/days online ratio. However, alternative videos platforms aimed at professionals should also be considered for educational purposes.

Effect of Resident Involvement on Patient Outcomes in Complex Laparoscopic Gastrointestinal Operations.

BACKGROUND: Multiple studies examining the impact of resident involvement on patient outcomes in general surgical operations have shown an associated increase in morbidity and operative time. However, these studies included basic and advanced laparoscopic and open operations. The aim of this study was to examine the impact of resident involvement on outcomes specifically in patients who underwent complex minimally invasive gastrointestinal operations. STUDY DESIGN: The American College of Surgeons NSQIP database was reviewed for patients who underwent laparoscopic colectomy and laparoscopic paraesophageal hernia and anti-reflux procedures between 2002 and 2010. Data were analyzed based on operations performed with a resident involved compared with those performed by an attending surgeon without resident involvement. Primary end points included risk-adjusted 30-day mortality, 30-day reoperation, and 30-day serious morbidity. Secondary end points were operative time, hospital length of stay, and 30-day overall morbidity. RESULTS: A total of 31,736 cases were analyzed; 63.3% of cases had a resident involved in the operation and 36.7% were performed by an attending without resident involvement. Operative time was significantly longer in cases performed with a resident (162 vs 138 minutes in attending-only cases; p < 0.01), however, there were no significant differences between groups with regard to hospital length of stay (4.5 vs 4.5 days, respectively). Compared with cases without resident involvement, risk-adjusted outcomes for cases with resident involvement showed no significant differences in 30-day serious morbidity (odds ratio = 1.03; 95% CI, 0.94-1.14; p = 1.0), 30-day mortality (odds ratio = 0.83; 95% CI, 0.60-1.15; p = 1.0), or 30-day reoperation (odds ratio = 0.93; 95% CI, 0.81-1.06; p = 1.0). CONCLUSIONS: Resident involvement in complex laparoscopic gastrointestinal procedures is associated with an increase in operative time with no impact on postoperative outcomes.

[Training curves for endosurgical interventions in neonates and infants].

AIM: To demonstrate training curves for endosurgical interventions in neonates and infants. MATERIAL AND METHODS: It was analyzed duration of thoracoscopic reconstruction of esophageal atresia (31 patients) and laparoscopic Nissen fundoplication (61 patients) performed for the period from January 2005 to December 2012. Graphs and tables reflecting correlation between duration and number of operations were framed. RESULTS: Figures demonstrate reducing duration of surgery with increase of endosurgical interventions number. CONCLUSION: Our data revealed that time necessary for minimally invasive procedures in infants and neonates decreases in process of experience accumulation.

Training model for laparoscopic Heller and Dor fundoplication: a tool for laparoscopic skills training and assessment-construct validity using the GOALS score.

BACKGROUND: Laparoscopic training demands practice. The transfer of laparoscopic skills from training models to real surgical procedures has been proven. The global operative assessment of laparoscopic skills (GOALS) score is a 5-item global rating scale developed to evaluate laparoscopic skills by direct observation. This scale has been used to demonstrate construct validity of several laparoscopic training models. Here, we present a low-cost model of laparoscopic Heller-Dor for advanced laparoscopic training. The aim of this study was to determine the capability of a training model for laparoscopic Heller-Dor to discriminate between different levels of laparoscopic expertise. METHODS: The performance of two groups with different levels of expertise, novices (<30 laparoscopic procedures PGY1-2) and experts (>300 laparoscopic procedures PGY4-5) was assessed. All participants were instructed to perform two tasks (esophageal myotomy and fundoplication). All the performances were recorded in a digital format. A laparoscopic expert who was blinded to subject's identity evaluated the recordings using the GOALS score. Autonomy, one of the five items of GOALS, was removed since the evaluator and the trainee did not have interaction. The time required to finish each task was also recorded. Performance was compared using the Mann-Whitney U test (p < 0.05 was significant). RESULTS: Twenty subjects were evaluated: ten in each group, using the GOALS score. The mean total GOALS score for novices was 7.5 points (SD: 1.64) and 13.9 points (SD: 1.66) for experts (p < 0.05).The expert group was superior in each domain of the GOALS score compared to novices: depth perception (mean: 3.3 vs 2 p < 0.05), bimanual dexterity (mean 3.4 vs 2.1 p < 0.05), efficiency (mean 3.4 vs 1.7 p < 0.05) and tissue handling (mean 3.6 vs 1.7 p < 0.05). With regard to time, experts were superior in task 1 (mean 9.7 vs 14.9 min p < 0.05) and task 2 (mean 24 vs 47.1 min p < 0.05) compared to novices. CONCLUSIONS: The laparoscopic Heller-Dor training model has construct validity. The model may be used as a tool for training of the surgical resident.

Effectiveness of short-term endoscopic surgical skill training for young pediatric surgeons: a validation study using the laparoscopic fundoplication simulator.

PURPOSE: Pediatric surgeons require highly advanced skills when performing endoscopic surgery; however, their experience is often limited in comparison to general surgeons. The aim of this study was to evaluate the effectiveness of endoscopic surgery training for less-experienced pediatric surgeons and then compare their skills before and after training. METHODS: Young pediatric surgeons (n = 7) who participated in this study underwent a 2-day endoscopic skill training program, consisting of lectures, box training and live tissue training. The trainees performed the Nissen construction tasks before and after training using our objective evaluation system. A statistical analysis was conducted using the two-tailed paired Student's t tests. RESULTS: The time for task was 984 ± 220 s before training and 645 ± 92.8 s after training (p < 0.05). The total path length of both forceps was 37855 ± 10586 mm before training and 22582 ± 3045 mm after training (p < 0.05). The average velocity of both forceps was 26.1 ± 3.68 mm/s before training and 22.9 ± 2.47 mm/sec after training (p < 0.1). The right and left balance of suturing was improved after training (p < 0.05). CONCLUSION: Pediatric surgery trainees improved their surgical skills after receiving short-term training. We demonstrated the effectiveness of our training program, which utilized a new laparoscopic fundoplication simulator.

Maintenance training for laparoscopic suturing: the quest for the perfect timing and training model: a randomized trial.

BACKGROUND: Although excellent training programs exist for acquiring the challenging skill required in laparoscopic suturing, without subsequent reinforcement, performance is prone to decay. Therefore, maintenance training is proposed to ensure better skill retention. This study aimed to elucidate the ideal timing and frequency of maintenance training as well as the best model to be used for this training. METHODS: After completing a proficiency-based laparoscopic suturing training, 39 medical students attended different maintenance programs represented by four groups: a control group without additional training (group 1), a massed training group with one supervised training session (150 min) after 2.5 months (group 2), and two distributed training groups with five monthly unsupervised training sessions of 30 min on a box trainer (group 3) or the LapMentor(®) (group 4). Retention testing, after 5 months, included suturing on a box trainer and on a cadaver porcine Nissen model. Performance scores (time and errors) were expressed in seconds. Afterward, time needed to regain proficiency was measured. RESULTS: On the box trainer, the median performance scores were 233 s (interquartile range [IQR] 27 s) for group 1, 180 s (IQR 55 s) for group 2, 169 s (IQR 26 s) for group 3, and 226 s (IQR 66 s) for group 4 (p = 0.03). No difference was seen between groups 2 and 3, both of which significantly outperformed groups 1 and 4. On the porcine Nissen model, no differences were detected between the groups (p = 0.53). Group 3 reached proficiency more quickly than the other groups. CONCLUSIONS: Maintenance training is a valuable and necessary addendum to proficiency-based training programs for laparoscopic suturing. A maintenance-training interval of 1 month with unsupervised training sessions on simple box trainers seems ideal. The LapMentor(®) did not show any benefit. Performance differences between groups did not translate to a clinically relevant model, indicating that transfer of training is not perfect.

Outcomes for trainees vs experienced surgeons undertaking laparoscopic antireflux surgery - is equipoise achieved?

BACKGROUND: There is a learning curve associated with laparoscopic antireflux surgery which has an impact on patient outcomes. It is unclear, however, whether this can be eliminated by supervision of early cases by experienced surgeons. The aim of this study was to evaluate the impact of training under supervision on outcomes for laparoscopic fundoplication. METHOD: Patients undergoing primary laparoscopic antireflux surgery from 1995 to 2009 were identified from a prospective database. Patients were classified according to whether they were operated on by an experienced consultant or supervised trainee, and sub-categorised according to the presence of a very large hiatus hernia. A standardised questionnaire was used to assess outcomes for heartburn, dysphagia and satisfaction at 1 and 5 years follow-up. Outcomes for the study groups were compared. RESULTS: One thousand seven hundred and ten patients underwent surgery; 1,112 were operated on by consultants and 598 by trainees. The peri-operative complication rate was not different between the groups, although in patients operated on by trainees, there were increased rates of endoscopic dilatation (9 vs. 5 % p = 0.014) and re-operation (9 vs. 6 %, p = 0.031), and a lower satisfaction rate (76 vs. 82 %, p = 0.044) within 5 years of surgery. All other outcomes were similar for trainees vs. consultants. CONCLUSION: The learning curve for laparoscopic fundoplication had a small, but statistically significant, impact on patient outcomes, with slightly lesser outcomes when surgery was undertaken by trainees, even when supervised by experienced surgeons. Although the differences were not large, they raise questions about equipoise and highlight ethical dilemmas with teaching new generations of surgeons.

Do not teach me while I am working!

BACKGROUND: The aim of this study was to determine if technical surgical experience enhances the learning of new cognitive information under multitasking conditions. METHODS: Junior (years 1-3) and experienced (years 4 and 5) general surgery residents performed a Nissen fundoplication on a synthetic model (the primary task). While performing the primary task, they listened to and memorized information describing the steps of a computer-assisted hip replacement surgery (the secondary task). Performance on the primary and secondary tasks was assessed using performance metrics and multiple-choice questions. RESULTS: The primary task was performed better by the senior than the junior trainees (P = .001, P = .007). The senior trainees also scored higher on the secondary task than the junior trainees (P = .001). CONCLUSIONS: Senior trainees have superior capacity to multitask. This may have direct implications on both clinical and simulation-based education, such that educators need to adjust the amount of information presented in accordance to trainees' levels of training.

[Benign esophageal disorders. Gastroesophageal reflux disease, diffuse esophageal spasm, achalasia]. / Benigne Erkrankungen des Ösophagus. Refluxkrankheit, diffuser Ösophagusspasmus, Achalasie.

Gastroesophageal reflux disease (GERD) is the most frequent benign disorder of the upper gastrointestinal (GI) tract and other defined disease entities, such as achalasia and diffuse esophageal spasm, also belong to this group. In addition to surgical therapy, medicinal therapy also has an important role in all 3 of these disorders. Therefore, it is very important to follow precise indication criteria based on diagnostic evaluation and patient selection as well as to use an optimal operative technique.The therapeutic spectrum for achalasia varies from Botox injections and endoscopic dilatation to laparoscopic myotomy which achieves a success rate up to 90%.Patients with diffuse spasm suffer from severe dysphagia, thoracic pain and burning sensations and even respiratory problems. Surgical therapy consists of thoracoscopic long myotomy and in selective cases with persisting pain even esophagectomy and gastric pull-up.Therapeutic options for GERD predominantly involve conservative medicinal therapy with proton pump inhibitors and selective laparoscopic antireflux procedures. Minimally invasive techniques have led to a higher acceptance of surgical therapy. The two major procedures most frequently used are total Nissen fundoplication and posterior partial Toupet fundoplication.