Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills.

Training on a video trainer or computer-based minimally invasive surgery trainer leads to improved benchtop laparoscopic skill. Recently, improved operative performance from practice on a video trainer was reported. The purpose of this study was three fold: (a) to compare psychomotor skill improvement after training on a virtual reality (VR) system with that after training on a video-trainer, (VT) (b) to evaluate whether skills learned on the one training system are transferable to the other, and (c) to evaluate whether VR or VT training improves operative performance. For the study, 50 junior surgery residents completed baseline skill testing on both the VR and VT systems. These subjects then were randomized to either a VR or VT structured training group. After practice, the subjects were tested again on their VR and VT skills. To assess the effect of practice on operative performance, all second-year residents (n = 19) were evaluated on their operative performance during a laparoscopic cholecystectomy before and after skill training. Data are expressed as percentage of improvement in mean score/time. Analysis was performed by Student's paired t-test. The VR training group showed improvement of 54% on the VR posttest, as compared with 55% improvement by the VT group. The VR training group improved more on the VT posttest tasks (36%) than the VT training group improved on the VR posttest tasks (17%) (p <0.05). Operative performance improved only in the VR training group (p <0.05). Psychomotor skills improve after training on both VR and VT, and skills may be transferable. Furthermore, training on a minimally invasive surgery trainer, virtual reality system may improve operative performance during laparoscopic cholecystectomy.

Improving operative performance using a laparoscopic hernia simulator.

BACKGROUND: Traditionally, the acquisition of surgical skill has occurred entirely in the operating room. To meet the expanding challenges of cost containment and patient safety, novel methods of surgical training utilizing ex-vivo workstations are being developed. The purpose of our study was to evaluate the impact of a laparoscopic training curriculum on surgical residents' operative performance. METHODS: Twenty-one surgery residents completed baseline laparoscopic total extraperitoneal (TEP) hernia repairs. Operative performance was evaluated using a validated global assessment tool. Each resident was then randomized to a control group or a trained group. A CD ROM, video, and simulator were used for training. At the end of the study, each resident's operative performance was again evaluated. RESULTS: Improvement was significantly greater in the trained group in five of the eight individual global assessment areas as well as the composite score (P <0.05). Questionnaire data suggested that training resulted in improved understanding of the TEP hernia repair (P = 0.01) and an increased willingness to offer the operation to patients with nonrecurrent unilateral hernias (P = 0.02). CONCLUSIONS: A multimodality laparoscopic TEP hernia curriculum improves residents' knowledge of the TEP hernia repair and comfort in performing the procedure, and may also improve actual operative performance.

Evaluating surgical competency with the American Board of Surgery In-Training Examination, skill testing, and intraoperative assessment.

BACKGROUND: Evaluation of surgical competency should include assessment of knowledge, technical skill, and judgment. The purpose of this study was to determine the relationship between the American Board of Surgery In-Training Examination (ABSITE), skill testing, and intraoperative assessment. METHODS: Postgraduate year 2 (PGY-2) and postgraduate year 3 (PGY-3) surgery residents (n = 33) were tested by means of (1) the ABSITE, (2) skill testing on a laparoscopic video-trainer, and (3) intra-operative global assessments during laparoscopic cholecystectomy. The Pearson correlation was used to determine the correlation between the ABSITE, skill testing, and intraoperative assessments. For the comparison of PGY-2 and PGY-3 resident performance, Wilcoxon rank sum tests were used. RESULTS: The ABSITE scores did not correlate with skill testing or intraoperative assessments (not significant). Skill testing correlated with the intraoperative composite score and with 4 of 8 operative performance criteria (P<.05). The ABSITE scores and skill testing were not different for PGY-2 and PGY-3 residents (not significant). Intraoperative assessments were better in 5 of 8 criteria and the composite score for PGY-3 versus PGY-2 residents (P<.05), which demonstrated construct validity. CONCLUSIONS: The ABSITE measures knowledge but does not correlate with technical skill or operative performance. Residency programs should use multiple assessment instruments to evaluate competency. There may be a role for both skill testing and intraoperative assessment in the evaluation of surgical competency.

Laparoscopic training on bench models: better and more cost effective than operating room experience?

BACKGROUND: Developing technical skill is essential to surgical training, but using the operating room for basic skill acquisition may be inefficient and expensive, especially for laparoscopic operations. This study determines if laparoscopic skills training using simulated tasks on a video-trainer improves the operative performance of surgery residents. STUDY DESIGN: Second- and third-year residents (n= 27) were prospectively randomized to receive formal laparoscopic skills training or to a control group. At baseline, residents had a validated global assessment of their ability to perform a laparoscopic cholecystectomy based on direct observation by three evaluators who were blinded to the residents' randomization status. Residents were also tested on five standardized video-trainer tasks. The training group practiced the video-trainer tasks as a group for 30 minutes daily for 10 days. The control group received no formal training. All residents repeated the video-trainer test and underwent a second global assessment by the same three blinded evaluators at the end of the 1-month rotation. Within-person improvement was determined; improvement was adjusted for differences in baseline performance. RESULTS: Five residents were unable to participate because of scheduling problems; 9 residents in the training group and 13 residents in the control group completed the study. Baseline laparoscopic experience, video-trainer scores, and global assessments were not significantly different between the two groups. The training group on average practiced the video-trainer tasks 138 times (range 94 to 171 times); the control group did not practice any task. The trained group achieved significantly greater adjusted improvement in video-trainer scores (five of five tasks) and global assessments (four of eight criteria) over the course of the four-week curriculum, compared with controls. CONCLUSIONS: Intense training improves video-eye-hand skills and translates into improved operative performance for junior surgery residents. Surgical curricula should contain laparoscopic skills training.

Measuring operative performance after laparoscopic skills training: edited videotape versus direct observation.

BACKGROUND AND PURPOSE: Global assessment by direct observation has been validated for evaluating operative performance of surgery residents after formal skills training but is time-consuming. The purpose of this study was to compare global assessment performed from edited videotape with scores from direct observation. MATERIALS AND METHODS: Junior surgery residents (N = 22) were randomized to 2 weeks of formal videotrainer skills training or a control group. Laparoscopic cholecystectomy was performed at the beginning and end of the rotation, and global assessment scores were compared for the training and control groups. Laparoscopic videotapes were edited: initial (2 minutes), cystic duct/artery (6 minutes), and fossa dissection (2 minutes). Two independent raters performed both direct observation and videotape assessments, and scores were compared for each rater and for interrater reliability using a Spearman correlation. RESULTS: Correlation coefficients for videotape versus direct observation for five global assessment criteria were <0.33 for both raters (NS for all values). The correlation coefficient for interrater reliability for the overall score was 0.57 (P = 0.01) for direct observation v 0.28 (NS) for videotape. The trained group had significantly better overall performance than the control group according to the assessment by direct observation (P = 0.02) but not by videotape assessment (NS). CONCLUSIONS: Direct observation demonstrated improved overall performance of junior residents after formal skills training on a videotrainer. Global assessment from an edited 10-minute videotape did not correlate with direct observation and had poor interrater reliability. Efficient and valid methods of evaluating operative performance await development.

Identification of high-risk residents.

BACKGROUND: Identification of high-risk residents allows remediation and support for administrative action when necessary. This study characterizes differences in documentation of marginally performing residents in a general surgery residency. METHODS: High-risk residents were identified by the former program director. Twenty-four of one hundred fifteen residents over a 10-year period had one to four problematic areas: cognitive, synthetic, family/health, and interpersonal skills. Outcomes included finished (18), voluntary withdrawal (1), and involuntary withdrawal (5). A case-control study matching controls to cases by date of entry into the training program was used. Records were reviewed for demographics, preentry qualifications, American Board of Surgery In-Training Exam (ABSITE) scores, letters of complaint or praise, events of counseling, and monthly ratings. The records of 48 residents were reviewed. Ward evaluations were on eight categories with a 5-point Leikert scale (3-unacceptable to 7-outstanding). The evaluation score assigns points only to low ratings. High scores represent progressively poorer performance. A Wilcoxon signed ranks test was used to compare the cases and controls for continuous variables. The McNemar test was used in comparisons of categorical data with binary outcomes. Exact P values are reported. RESULTS: Objective data were similar for both groups. Study residents tended to score higher on monthly evaluations at Year 2 and by Year 3 this achieved significance (0.026). Study residents were more likely to have negative faculty letters (0.016) and events of counseling by a faculty member (0.017) and the program director (0.005). CONCLUSIONS: Identification of residents at risk should begin as early as possible during training. A combination of faculty evaluations and evidence of letters of counseling can detect high-risk residents. Programs may use such indicators to support decisions regarding remedial work or administrative action.

A clinical pathway for inguinal hernia repair reduces hospital admissions.

BACKGROUND: Clinical pathways have been advocated as a means to improve and standardize patient care while reducing costs through improved efficiency. This study examines the hypothesis that development of a clinical pathway reduces hospital admissions in a Veterans Affairs (VA) medical center. MATERIALS AND METHODS: For the year prior to June 1997, 168 elective inguinal herniorrhaphies were performed. This constituted the prepathway (pre-P) group. One hundred ninety-six elective inguinal herniorrhaphies were performed during the year following institution of the clinical pathway-the postpathway (post-P) group. RESULTS: Hospital admissions were compared between the two groups. In the pre-P group 61 of the 168 patients (36%) were admitted while 29 of the 196 patients (15%) in the post-P group were admitted (P < 0.001). In the pre-P group 27 of the 53 patients reviewed (51%) had either no justification or inadequate justification for admission. In the post-P group 8 of the 29 patients admitted (28%) had inadequate justification (pre-P vs post-P, P = 0.124). Common reasons for admission included pain, perioperative complications, and concurrent medical problems or surgical procedures. The most common single cause other than pain was urinary retention. The average age of patients requiring admission was greater both pre-P and post-P. CONCLUSIONS: We conclude that institution of a clinical pathway for inguinal herniorrhaphy decreased hospital admissions. The reasons for this decrease are probably multifactorial and include improvements in physician and staff awareness. The decrease in unnecessary admissions should result in more efficient use of hospital resources.

Factors affecting recurrence following incisional herniorrhaphy.

The purpose of this study was to determine the influence of chronic illness, obesity, and type of repair on the likelihood of recurrence following incisional herniorrhaphy. The medical records of 77 patients who underwent elective repair of a midline incisional hernia at the Dallas Veterans Affairs Medical Center between 1991 and 1995 were reviewed. Demographic data, presence of chronic illnesses, type of repair, and presence of recurrence were noted. Ninety-six percent of the patients were men, with an average age of 59 years. More than 50% of the patients had chronic lung or cardiac diseases and more than 40% weighed > or = 120% of their ideal body weight and had a body mass index (BMI) > or = 30. Sixty-two percent of the patients underwent primary reapproximation of the fascia (tissue repair), whereas 38% underwent repair with prosthetic material (prosthetic repair). The overall recurrence rate was 45%, with a median follow-up of 45 months (range 6-73). Seventy-four percent of the recurrences presented within 3 years of repair. The recurrence rate for those patients undergoing a tissue repair was 54%, whereas the recurrence rate following prosthetic repair was 29%. The incidence of recurrence for patients with pulmonary or cardiac disease or diabetes mellitus was similar to that of patients without these illnesses. The percent ideal body weight and BMI of patients who developed a recurrent hernia, particularly following a prosthetic repair, were significantly greater than those of patients whose repairs remained intact. These data strongly support the use of prosthetic repairs for incisional hernias, particularly in patients who are overweight.

Gender-related attrition in a general surgery training program.

BACKGROUND: Attracting and retaining highly qualified applicants to careers in surgery is a goal of residency training programs. Few studies of attrition in residency exist. This study examines the hypothesis that reasons for attrition during general surgery training are different for male and female trainees. MATERIALS AND METHODS: NRMP matching information was used to evaluate attrition rates in a categorical general surgery (CGS) residency program from 1984 through 1996. The records of all matched residents were examined to determine the association between gender and attrition outcomes. Outcome variables included: voluntary vs involuntary withdrawal and the reasons for withdrawal. RESULTS: During the study period 132 candidates matched (103 men and 29 women) into CGS positions. Of that group, 18 residents, 11 (10.7%) from the male and 7 (24.1%) from the female cohorts withdrew. Only three involuntary withdrawals occurred. Women were 2.26 times more likely to withdraw than men, a finding that is not statistically significant (P = 0. 073). Women rarely left for preference of other specialty (relative risk 0.25), whereas men were 4 times more likely to leave for this reason. CONCLUSION: These numbers suggest that women are at higher risk of leaving general surgery training than men. When women do leave, it is more likely for family reasons such as lifestyle considerations or to join a spouse in another geographic location. Such findings support the conclusion that fundamental differences exist in decisions regarding attrition between genders. National studies of attrition and the reasons for leaving are needed to develop specific strategies promoting retention for both genders.