Developing a curriculum for advanced fellowship training in complex cancer for the UK.

AIM: Surgery for complex colorectal cancer is elaborate: preoperative assessment, patient selection, radiological interpretation, operative strategy, operative technical skills, operative standardization, postoperative care and management of complications are all critical components. Given this complexity, training that encompasses all these crucial aspects to generate suitably edified surgeons is essential. To date, no curriculum exists to guide training in advanced and recurrent pelvic malignancy, particularly for complex colorectal cancer. Such a curriculum would potentially offer numerous advantages, not only for individual surgeons but also for research, governance, international collaboration and benchmarking. The aim of this study was to design and develop a framework for a curriculum for fellowship training in complex colorectal cancer that encompasses pelvic exenteration surgery. METHOD: Kern described a six-step method for curriculum design that is now widely adopted in medical education. Our study utilizes steps 1-4 of Kern's method to develop a syllabus and assessment framework for curriculum development for fellowship training in complex colorectal cancer encompassing pelvic exenteration. A literature review was conducted to address step 1, followed by targeted needs assessment in step 2 by conducting focus groups with trainees, fellows and experts to identify learning needs and goals with objective setting for step 3. An expert consensus group then voted on these recommendations and developed educational strategy recommendations as step 4. For the purposes of brevity, 'pelvic exenteration' in the text is taken to also encompass extended and multivisceral resections that fall under the remit of complex [colorectal] cancer. RESULTS: Step 1 of Kern's method identified a gap in the literature on curricula in complex cancer surgery. Step 2 identified key areas regarded as learning needs by trainees, including anatomy, hands-on experience and case volume. Step 3 defined the goals and objectives of a fellowship curriculum, defined in six domains including theoretical knowledge, decision-making, technical skills, postoperative management and continuing professional development. Finally, as a prelude to stages 5 and 6, a strategy for implementation and for feedback and assessment was agreed by an expert consensus meeting that defined case volume (a minimum of 20 pelvic exenteration operations within a fellowship period) and coverage of this syllabus with derived metrics. CONCLUSIONS: Our working group has developed a curriculum framework for advanced fellowship training in complex cancer in the UK. Validation is needed through implementation, and affirmation of its utility, both nationally and internationally, must be sought.

The deconstructed procedural description in robotic colorectal surgery.

Increasing robotic surgical utilisation in colorectal surgery internationally has strengthened the need for standardised training. Deconstructed procedural descriptions identify components of an operation that can be integrated into proficiency-based progression training. This approach allows both access to skill level appropriate training opportunities and objective and comparable assessment. Robotic colorectal surgery has graded difficulty of operative procedures lending itself ideally to component training. Developing deconstructed procedural descriptions may assist in the structure and progression components in robotic colorectal surgical training. There is no currently published guide to procedural descriptions in robotic colorectal surgical or assessment of their training utility. This scoping review was conducted in June 2022 following the PRISMA-ScR guidelines to identify which robotic colorectal surgical procedures have available component-based procedural descriptions. Secondary aims were identifying the method of development of these descriptions and how they have been adapted in a training context. 20 published procedural descriptions were identified covering 8 robotic colorectal surgical procedures with anterior resection the most frequently described procedure. Five publications included descriptions of how the procedural description has been utilised for education and training. From these publications terminology relating to using deconstructed procedural descriptions in robotic colorectal surgical training is proposed. Development of deconstructed robotic colorectal procedural descriptions (DPDs) in an international context may assist in the development of a global curriculum of component operating competencies supported by objective metrics. This will allow for standardisation of robotic colorectal surgical training and supports a proficiency-based training approach.

The rise of robotic colorectal surgery: better for patients and better for surgeons.

Robotic colorectal surgery represents a major technological advancement in the treatment of patients with colorectal disease. Several recent randomized controlled trials comparing robotic colorectal surgery with laparoscopic surgery have demonstrated improved short-term patient outcomes in the robotic group. Whilst the primary focus of research in robotic surgery has been on patient outcomes, the robotic platform also provides unparalleled benefits for the surgeon, including improved ergonomics and surgeon comfort, with the potential to reduce occupational injuries and prolong career longevity. It is becoming clear that robotic surgical systems improve patient outcomes and may provide significant benefits to the surgical workforce.

Evaluating the Educational Value of Cancer Registries - a Systematic Review and Thematic Analysis.

Cancer registries encompass a broad array of functions that underpin cancer control efforts. Despite education being fundamental to improving patient outcomes, little is known regarding the educational value of cancer registries. This review will evaluate the educational value of cancer registries for key stakeholders as reported within published literature and identify opportunities for enhancing their educational value. Four databases (Ovid Medline, Embase, CINAHL and Web of Science) were searched using a predefined search strategy in keeping with the PRISMA statement. Data was extracted and synthesised in narrative format. Themes and frequency of discussion of educational content were explored using thematic content analysis. From 952 titles, ten eligible studies were identified, highlighting six stakeholder groups. Educational outcomes were identified relating to clinicians (6/10), researchers (5/10), patients (4/10), public health organisations (3/10), medical students (1/10) and the public (1/10). Cancer registries were found to educationally benefit key stakeholders despite educational value not being a key focus of any study. Deliberate efforts to harness the educational value of cancer registries should be considered to enable data-driven quality improvement, with the vast amount of data promising ample educational benefit.

Exploring the educational value of the general surgical outpatient clinic: a systematic review.

Purpose: Optimising opportunities for exposure and learning in the clinical environment is a priority for surgical education. The surgical outpatient clinic provides a setting for engaging with the patient journey while gaining essential surgical knowledge and skills. This systematic review seeks to determine the role of the outpatient clinic in current surgical education for multiple levels of learners and identify strategies to improve educational utility. Methods: A systematic search strategy was conducted across Medline (OVID), Embase, PubMed, and Web of Science databases according to PRISMA guidelines. A comprehensive grey literature search for evaluation of international postgraduate surgical curricula was also performed. Publications were included if they discussed or utilised the general surgical outpatient clinic in an educational context. Results: Nine publications were included in this review. Educational interventions in a surgical outpatient clinic setting were discussed in three publications and two publications presented observational data relating to educational opportunities in the surgical outpatient clinic. Four postgraduate surgical curricula outlined the current approaches to surgical education in the outpatient clinic setting. Assessment of included studies by Kirkpatrick level of evidence highlighted that included studies did not investigate high-order educational outcomes. Thematic analysis of curricula was utilised to build a common set of learning outcomes. Conclusions: Educational interventions were found to improve learning outcomes, particularly those that facilitated active student participation. Postgraduate surgical curricula utilise the surgical outpatient clinic and recognise its importance in surgical training through the implementation of outpatient-based learning objectives which serve as fundamental components of training. Common learning objectives can be used to direct further research into the efficacy of this educational context. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-023-00106-8.

A systematic review of video-based educational interventions in robotic surgical training.

As robotic surgical procedures become more prevalent in practice, there is a demand for effective and efficient educational strategies in robotic surgery. Video has been used in open and laparoscopic surgery to instruct trainees in the acquisition of operative knowledge and surgical skill. Robotic surgery is an ideal application of video-based technology given the access of video recording directly from the console. This review will present the evidence base for video-based educational tools in robotic surgery to guide the development of future educational interventions using this technology. A systematic review of the literature was performed using the key words "video" "robotic surgery" and "education". From a total of 538 results, 15 full text articles were screened. Inclusion criteria were the presentation of an educational intervention using video and the application of this intervention to robotic surgery. The results of 10 publications are presented in this review. Analysis of the key concepts presented in these publications revealed three themes: video as technology, video as instruction, video as feedback. All studies showed a video-based learning had a positive effect on educational outcomes. There are limited published studies looking specifically at the use of video as an educational intervention in robotic surgical training. Existing studies primarily focus on the use of video as a review tool for skill development. There is scope to expand the use of robotic video as a teaching tool through adaptation of novel technology such as 3D headsets and concepts of cognitive simulation including guided mental imagery and verbalisation.

How I Do It: Structured Narration for Cognitive Simulation-based Training in Robotic Surgery.

Video in robotic surgical education is an important and effective training tool. The educational benefit of video training tools can be enhanced by incorporating cognitive simulation using mental imagery. Narration of robotic surgical training video is an under-explored aspect of video design. Narration can be structured to stimulate visualization and procedural mental mapping. To achieve this, narration should be constructed to follow operative phases and steps and include the procedural, technical and cognitive components. This approach provides a foundation for building an understanding of the key concepts required to safely complete a procedure.

A systematic review of the application of 3D-printed models to colorectal surgical training.

BACKGROUND: The aim of this review was to explore the role of three-dimensional (3D) printing in colorectal surgical education and procedural simulation, and to assess the effectiveness of 3D-printed models in anatomic and operative education in colorectal surgery. METHODS: A systematic review of the literature was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify relevant publications relating to the use of 3D-printed models in colorectal surgery in an educational context. The search encompassed OVID Medline, Web of Science and EMBASE including papers in English published from 1 January 1995 to 1 January 2023. A total of 1018 publications were screened, and 5 met the criteria for inclusion in this review. RESULTS: Four distinct 3D models were described across five studies. Two models demonstrated objective benefits in the use of 3D-printed models in anatomical education in academic outcomes at all levels of learner medical experience and were well accepted by learners. One model utilised for preoperative visualisation demonstrated improved operative outcomes in complete mesocolic excision compared with preoperative imaging review, with a 22.1% reduction in operative time (p < 0.001), 9.2% reduction in surgical duration (p = 0.035) and 37.3% reduction in intraoperative bleeding volume amongst novice surgeons (p < 0.01). Technical simulation has been demonstrated in a feasibility context in one model but remains limited in scope and application on account of the characteristics of available printing materials. CONCLUSIONS: 3D printing is well accepted and effective for anatomic education and preoperative procedural planning amongst colorectal surgeons, trainees and medical students but remains a technology in the early stages of its possible application. Technological advancements are required to improve the tissue realism of 3D-printed organ models to achieve greater fidelity and provide realistic colorectal surgical simulations.

Transferability of robotic console skills by early robotic surgeons: a multi-platform crossover trial of simulation training.

Robotic surgical training is undergoing a period of transition now that new robotic operating platforms are entering clinical practice. As this occurs, training will need to be adapted to include strategies to train across various consoles. These new consoles differ in multiple ways, with some new vendors using flat screen open source 3D enhanced vision with glasses and differences in design will require surgeons to learn new skills. This process has parallels with aviation credentialling across different aircraft described as type rating. This study was designed to test the hypothesis that technical robotic console operating skills are transferrable across different robotic operating platforms. Ten participants sequentially completed four Mimic®(Surgical Science) simulation exercises on two different robotic operating platforms (DaVinci®, Intuitive Surgical and HUGO™ RAS, Medtronic). Ethical approval and informed consent were obtained for this study. Groups were balanced for key demographics including previous robotic simulator experience. Data for simulation metrics and time to proficiency were collected for each attempt at the simulated exercise and analysed. Qualitative feedback on multi-platform learning was sought via unstructured interviews and a questionnaire. Participants were divided into two groups of 5. Group 1 completed the simulation exercises on console A first then repeated these exercises on console B. Group 2 completed the simulated exercises on console B first then repeated these exercises on console A. Group 1 candidates adapted quicker to the second console and Group 2 candidates reached proficiency faster on the first console. Participants were slower on the second attempt of the final exercise regardless of their allocated group. Quality and efficiency metrics and risk and safety metrics were equivalent across consoles. The data from this investigation suggests that console operating skills are transferrable across different platforms. Overall risk and safety metrics are within acceptable limits regardless of the order of progression of console indicating that training can safely occur across multiple consoles contemporaneously. This data has implications for the design of training and certification as new platforms progress to market and supports a proficiency-based approach.

What are clinically relevant performance metrics in robotic surgery? A systematic review of the literature.

A crucial element of any surgical training program is the ability to provide procedure-specific, objective, and reliable measures of performance. During robotic surgery, objective clinically relevant performance metrics (CRPMs) can provide tailored contextual feedback and correlate with clinical outcomes. This review aims to define CRPMs, assess their validity in robotic surgical training and compare CRPMs to existing measures of robotic performance. A systematic search of Medline and Embase databases was conducted in May 2022 following the PRISMA guidelines. The search terms included Clinically Relevant Performance Metrics (CRPMs) OR Clinically Relevant Outcome Measures (CROMs) AND robotic surgery. The study settings, speciality, operative context, study design, metric details, and validation status were extracted and analysed. The initial search yielded 116 citations, of which 6 were included. Citation searching identified 3 additional studies, resulting in 9 studies included in this review. Metrics were defined as CRPMs, CROMs, proficiency-based performance metrics and reference-procedure metrics which were developed using a modified Delphi methodology. All metrics underwent both contents and construct validation. Two studies found a strong correlation with GEARS but none correlated their metrics with patient outcome data. CRPMs are a validated and objective approach for assessing trainee proficiency. Evaluating CRPMs with other robotic-assessment tools will facilitate a multimodal metric evaluation approach to robotic surgery training. Further studies should assess the correlation with clinical outcomes. This review highlights there is significant scope for the development and validation of CRPMs to establish proficiency-based progression curricula that can be translated from a simulation setting into clinical practice.

Recommendations for the design of video-based educational interventions as instructional tools in robotic surgical training.

Video-based instructional tools are an important emerging component of robotic surgical education. However, there is a paucity of literature on the structure of video as an instructional tool in robotic surgery. This paper reviews the literature on video-based instructional tools and provides a series of recommendations for the structure of a video- based training tool in robotic surgery. Key educational aspects to consider in designing a video training tool are student engagement, content validity, cognitive load, and active learning. Key recommendations for structure of instructional videos are that videos should be short, presented in modular blocks with appropriate narration and engagement strategies.

A systematic review and meta-analysis of robotic resections for diverticular disease.

AIM: Resection of diverticular disease can be technically challenging. Tissue planes can be difficult to identify intraoperatively due to inflammation or fibrosis. Robotic surgery may improve identification of tissue planes and dissection which can facilitate difficult minimally invasive resections. This systematic review and meta-analysis evaluates the role of robotic surgery compared to laparoscopic surgery in diverticular resection. METHODS: A systematic review and meta-analysis was performed in accordance with the PRISMA statement. The search was completed using PubMed, OVID MEDLINE and EMBASE. A total of 490 articles were retrieved, and studies reporting primary outcomes for robotic diverticular resection were included in the final analysis. A meta-analysis of studies comparing robotic and laparoscopic surgery was performed on rate of conversion to open surgery and complications. RESULTS: Fifteen articles (8 cohort studies and 7 case series) reporting 3711 robotic diverticular resections were analysed. In comparison to laparoscopic, robotic surgery for diverticular disease was associated with a reduced conversion to open and a longer operating time. Meta-analysis showed robotic resection was associated with a lower conversion rate compared to laparoscopic surgery (OR: 0.57; 95% CI: 0.49-0.66, p < 0.001). There was no significant difference in grade III and above complications (OR: 0.74; 95% CI: 0.49-1.13, p = 0.17). Operating time was longer with a robotic approach (Hedge's G: 0.43; 95% CI: 0.04-0.81, p = 0.03). CONCLUSION: Robotic resection is a feasible and safe option in diverticular disease. Although associated with a longer operating time, robotic surgery may render diverticular disease resectable with a minimally invasive approach that would have otherwise necessitated a laparotomy. Randomised controlled data is required to better define the role of robotic surgery for diverticular disease resections.

The educational value of the multi-disciplinary meeting (MDM) in surgical oncology: A systematic review and thematic content analysis.

Multidisciplinary meetings are an important part of cancer care and surgical planning. However, there is also an important educational role of MDMs in training the next generation of surgical oncologists. This systematic review (SR) aimed to examine the current educational role of the surgical oncology MDM and identify areas for improving educational value. Medline, OVID, EMBASE, CINHIL and Web of Science were searched using a predefined search strategy in keeping with the PRISMA statement. Data was analysed and synthesized in narrative format and thematic content analysis was performed. Three main groups of studies were identified, those with: 1. A simulated non-clinical MDM (3/13), 2. clinical MDMs with a defined educational intervention (1/13) and 3. observational studies that described the educational benefit of the clinical MDM with no intervention (9/13). Satisfaction rates were high and learning outcomes improved where an intervention to improve the educational content of the MDM had been implemented(simulated or non-simulated). Respondents considered the MDM a valuable tool for learning non-technical skills and training surgical oncologists and medical students. Using defined interventions e.g. debriefing post MDM, or simulation can improve the educational benefit for learners. Qualitative analysis identified clinical knowledge, decision making and the acquisition of non-technical skills as the key themes within included studies.

A systematic scoping review of the initial experience with laparoscopic radical antegrade modular pancreatosplenectomy for pancreatic malignancy.

BACKGROUND: Laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) is a validated surgical approach for the surgical treatment of pancreatic malignancies of the body and tail of the pancreas. Open (O-) RAMPS is an established technique that offers oncological efficacy and acceptable post-operative outcomes when compared to standard distal pancreatectomy for pancreatic malignancies. This review aimed to determine the types of evidence available for L-RAMPS, and its selection criteria and reported outcomes, using systematic scoping review methodology. METHODS: A systematic review of available literature was performed in September 2020. Data extracted included patient selection criteria, technical details, total number of L-RAMPS procedures performed, lymph nodes retrieved, resection margins, survival, LOS and complications. RESULTS: Eight papers were eligible for inclusion, totalling 92 cases. There were no studies that directly compared O- to L-RAMPS. All reports were small retrospective cohorts with 3-30 patients. Selection criteria were reported in 4/8 studies and differed between studies. Technique descriptions were included in 6/8 studies. Studies reported a median of 5 (range 1-9) out of ten operative and clinical outcomes, including operative time median range 188-431 min, intraoperative blood loss median range 18-445 mL, R0 resection rate median range 91-100%, number of lymph nodes median range 11-43, and length of stay median range 12-20 days. CONCLUSIONS: L-RAMPS is infrequently reported in the literature. There are currently no data to allow for direct comparison of O- and L-RAMPS. Reports of L-RAMPS have an acceptable oncological and safety profile. A standardised description of the operative technique and outcome reporting, as well as specific training initiatives may be beneficial to broaden the application of L-RAMPS.

Use of social media for surgical education in Australia and New Zealand.

BACKGROUND: Social media are an increasingly important tool for educators, although their use for surgical education in Australia and New Zealand (ANZ) has not been quantified. This study aimed to determine the social media presence of surgical training institutions in ANZ, quantify the proportion of their social media content that is educational, compare engagement between educational and non-educational content, and determine perspectives on using social media for education. METHODS: An online search was conducted in October 2018 to determine the social media presence of surgical training institutions accredited to deliver under- and post-graduate surgical education in ANZ. All their posts on Facebook and Twitter from November 2017 to October 2018 were categorized as educational or non-educational. Engagement on Twitter was analysed using retweets. An online survey was distributed to each institution to investigate their social media strategy and opinions on the use of social media for surgical education. RESULTS: Seven out of 37 (19%) surgical training institutions had active social media accounts. Educational content accounted for 677/4615 (14.7%) of their posts. Educational content was retweeted more often than non-educational content (17.2 versus 5.4, P = 0.002). Seven out of 37 (19%) institutions responded to the survey, with one respondent having a policy for and utilising social media for surgical education. CONCLUSIONS: Social media are being used by a minority of surgical training institutions for educational purposes in ANZ. Social media content is primarily non-educational although educational posts attract more engagement. Further research is required to assess the efficacy of surgical education on social media.

Primary abdominal Tyre blast injury: A rare case of intra-abdominal trauma.

Tyre blast injuries are an infrequently encountered but important cause of significant injury. Due to their rare nature tyre blast injuries are often not recognised as major trauma and this can pose significant risk to patient.