Development Of Surgical Skills Research Articles

EP.TU.153Face to face teaching in the covid era: Basic Surgical Skill Development

AimsAccording to literature,newly qualified doctors are at risk of being unable to perform practical procedures safely. This has been exacerbated by the disruptions to training and education which the covid-19 pandemic has caused. This intensive course has been developed to improve basic surgical skills and improve confidence in simple wound closure, to mitigate these disruptions.MethodsCandidates attended a three-part course in small groups, where they learned hand ties, basic laparoscopic skills and wound closure on animal models. Self assessment data were collected pre and post workshop on a Likert scale. All data was assessed using basic descriptive analysis.ResultsData was collected from 13 participants (M:F, 5:8) at the level of foundation year 1(61.5%,n=8) and foundation year 2(38.5%,n=5). Only 38.5% (n = 5) had previous basic surgical skills training. Our delegates reported an improvement in the following surgical skills: suturing (n = 11, 84.6%), hand tying (n = 10, 76.9%), laparoscopic skills (n = 10, 76.9%). Overall 61.5% (n = 8) of our delegates reported an improvement in all three domains.ConclusionsParticipants reported limited exposure prior to this course despite successfully completing an undergraduate curriculum. Overall, participants' self-scores improved in all three taught surgical skills. We believe ourcourse is a practical and reproducible solution to help bridge training gaps, which can be safely conducted with social distancing measures.

Assessment of Obstetric and Gynecology Residents: An Assessment of Attitudes before and after Initiation of a Robotic Training Curriculum

Study Objective Surgical training in gynecology is constantly evolvingwith new techniques and practices developing. Surgical training modules are of particular importance in academic training centers. Robotic surgical training poses a challenge to both leaders and learners to provide comprehensive and consistent education for the development of appropriate surgical skills. The purpose of this study was to evaluate for improvement in resident comfort level after initiation of a formal robotics training curriculum. Design This was an IRB exempt survey of residents within an Obstetrics and Gynecology (OBGYN) training program. Two voluntary, anonymous questionnaires were distributed to residents to evaluate their comfort level both before and after initiation of a formal robotic curriculum. A comparative assessment was performed to assess for improved resident comfort levels training on the robotic console. Setting N/A. Patients or Participants Participants in this study included post-graduate years (PGY) 1-4 residents enrolled in the 2019-2020 academic year completed at the University of Florida (UF) Health-Jacksonville Obstetrics and Gynecology (OBGYN) residency program. Interventions A formal robotic surgical training curriculum was introduced which consisted of online modules, documented training on the SimNow robotic simulator and in-person in-service of the DaVinci platform in a non-operative setting. Measurements and Main Results After analyzing results of the surveys, consistent improvement in resident comfort level with regards to robotic surgery was noted in all eight of the subjective questions included on the survey. Participants’ comfort level and understanding statistically improved in response to questions 1-5 and 7 with p value < 0.05. Conclusion Given these findings, we recommend routine implementation of a formal robotic training program for surgical trainees in an academic setting. Implementation of a standardized robotic surgery-training curriculum can accelerate trainee's readiness and their comfort level in performing robotic surgery during residency, therefore optimizing their surgical training prior to graduation. Surgical training in gynecology is constantly evolvingwith new techniques and practices developing. Surgical training modules are of particular importance in academic training centers. Robotic surgical training poses a challenge to both leaders and learners to provide comprehensive and consistent education for the development of appropriate surgical skills. The purpose of this study was to evaluate for improvement in resident comfort level after initiation of a formal robotics training curriculum. This was an IRB exempt survey of residents within an Obstetrics and Gynecology (OBGYN) training program. Two voluntary, anonymous questionnaires were distributed to residents to evaluate their comfort level both before and after initiation of a formal robotic curriculum. A comparative assessment was performed to assess for improved resident comfort levels training on the robotic console. N/A. Participants in this study included post-graduate years (PGY) 1-4 residents enrolled in the 2019-2020 academic year completed at the University of Florida (UF) Health-Jacksonville Obstetrics and Gynecology (OBGYN) residency program. A formal robotic surgical training curriculum was introduced which consisted of online modules, documented training on the SimNow robotic simulator and in-person in-service of the DaVinci platform in a non-operative setting. After analyzing results of the surveys, consistent improvement in resident comfort level with regards to robotic surgery was noted in all eight of the subjective questions included on the survey. Participants’ comfort level and understanding statistically improved in response to questions 1-5 and 7 with p value < 0.05. Given these findings, we recommend routine implementation of a formal robotic training program for surgical trainees in an academic setting. Implementation of a standardized robotic surgery-training curriculum can accelerate trainee's readiness and their comfort level in performing robotic surgery during residency, therefore optimizing their surgical training prior to graduation.

1420 ViRtual prOficiency Based prOgression for Robotic Training (VROBOT): A Prospective Cohort Study Protocol

Abstract Introduction Robotic surgery is an evolving field that requires specialist training. Historically, robotic surgery training has lacked standardisation. Recently, training centres have introduced proficiency-based modules and curriculums to certify and progress the skills of novice robotic surgeons. However, training tends to be self-directed and non-interactive. Limited interactive teaching does exist but can be inaccessible and expensive. We aim to validate the effectiveness of the current Fundamentals of Robotic Surgery (FRS) training curriculum with the addition of interactive virtual classroom teaching. Method 16 novice surgical trainees will be assigned to two training groups. The interventions will be implemented following a one-week robotic skills induction. Both groups will receive access to the FRS curriculum for one week. The intervention group will additionally receive virtual classroom robotic skills training. The primary outcome will be the objective performance scores after training using a synthetic model based on task errors, time taken and contact pressure. In week 3, each group will receive the alternate intervention and objective performance scores will be measured to determine the trajectory of scores. Results Significant objective performance improvement following the intervention will be indicative of intervention quality. Conclusions This will be the first feasibility study evaluating the efficacy of interactive virtual robotic surgery training. It will determine the effect size of virtual classroom training on the development of basic robotic surgical skills in addition to the proficiency-based FRS curriculum. The findings will assist the development and implementation of further resource-efficient virtual robotic surgical skills training programs.

557 Becoming Virtual: Lessons Learned from Moving Wessex Core Surgical Training Deanery Teaching On-Line

Abstract Aim Surgical training has been significantly impacted by COVID-19. Social distancing requirements mandated a change in face-to-face teaching with many deaneries adopting ‘virtual' sessions. Surgical training does not immediately lend itself to e-learning owing to its hands-on nature. We describe our experiences in developing a virtual teaching program for Core Surgical Trainees within the Wessex Deanery. We provide tips, tricks, and pitfalls for educators to establish or improve similar programs. Method From June 2020 monthly, in-person teaching was replaced with virtual sessions. Quantitative and qualitative feedback directed improvements in the program. In addition to knowledge-based lectures we integrated on-line learning tools (LapPass) and utilised surgical videos to ensure continued development of surgical skills. Mock MRCS and ST3 interviews were conducted remotely using ‘break-out rooms. Where face-to-face teaching was essential (Boot Camp, Field Camp) safety was ensured with reduced numbers (split sessions), social distancing and appropriate PPE. Results All trainees strongly agreed (67%) or agreed (33%) that virtual teaching works well. There were no significant differences in feedback scores compared with face-to-face teaching. Attendance increased by 42%. Interactivity was maintained with ‘cameras on, mics off', polling apps and chat box function. Advantages include uploading webinars for future review, ability for educators to present from multiple locations, increased availability and breadth of speakers and reduced burden on clinical commitments. Conclusions The COVID-19 pandemic has dictated an evolution of surgical teaching. Virtual teaching has many advantages over face-to-face and should continue to play a part in postgraduate medical education, even after social distancing restrictions are lifted.

1306 Recommendations for the Use of Simulators in Cardiothoracic Surgical Training

Abstract Aim To systematically review the simulators that are currently available for cardiothoracic surgical procedures and the validation evidence supporting them. Additionally, to recommend several simulators for training based on analysis of results. Method A systematic literature search of the MEDLINE® (1946 to December 2019) and EMBASE® (1947 to December 2019) databases was performed to identify simulators for basic skills and procedures in cardiothoracic surgery. A selection of keywords and MeSH terms were used to execute the literature search. After identification of relevant articles, data were extracted and analysed. Results Ninety simulators were found in eighty-one articles. Simulators for basic skills (n=24) and coronary artery bypass graft (n=22) were the most commonly described, followed by miscellaneous (n=14), valve surgery (n=13), thoracic lobectomy (n=10), and mechanical circulatory support (n=7). The majority of models were either benchtop (n=42) or hybrid (n=33) modalities. Evidence of validity was demonstrated in 38 (42.2%) simulators. Five (5.6%) simulators had three or more elements of validity established and only one (1.1%) accomplished full validation. Conclusions Five simulators were recommended for supplemental training in cardiothoracic surgery. Low-fidelity models can provide a broad foundation for surgical skills development and high-fidelity simulators can be used for immersive training scenarios and appraisals. These should be utilised in early training, at which point the learning curve of trainees is steepest.

Development of the fundamentals of thoracic robotic surgery curriculum.

A great technological revolution in surgery occurred with the introduction of laparoscopic and other minimally invasive procedures, with enormous patient benefits. Robotic-assisted surgery (RAS) is a form of minimally invasive surgery that overcomes some of the limitations of laparoscopic techniques. Until recently, there were few standardized curricula for RAS. The Fundamentals of Robotic (FRS) developed a process through expert consensus conferences to develop an effective and validated curriculum for basic robotic surgery. A specialty specific curriculum for thoracic robotic surgery is also needed. The Fundamentals of Thoracic Robotic Surgery (FTRS) Consensus Conference brought together expert thoracic surgeons to build upon the accomplishments of FRS and incorporate the experiences of thoracic societies and academic institutions to establish a standardized FTRS curriculum for the development and maintenance of specialty-specific robotic surgical skills. A task deconstruction was completed for the thoracic ‘signature’ procedure, the lobectomy and training items and potential errors were identified for each step of the procedure. A final outline of the FTRS curriculum was developed during the conference and physical and virtual reality thoracic surgery training models were discussed. Following the conference, the steering committee completed the FTRS curriculum with editorial review from all stakeholders. The FTRS consensus conference followed the validated FRS model but in an accelerated process due to important groundwork set by experts in the FRS consensus conferences. A full online curriculum and supporting psychomotor skills training and team communication has been developed for the lobectomy procedure.

A Review of the Impact of COVID-19 Pandemic on Urology Residence Training

Abstract Introduction and Objective: Since March 11, 2020, when the World Health Organization declared COVID-19 as a pandemic, a significant strain was placed on the worldwide health-care system. Although urology does not stand at the frontline of care for patients with COVID-19, every practicing urologist has been affected by the global outbreak. The impact of the COVID-19 pandemic on urology residency training was evaluated taking into account the residents’ point of view regarding these unprecedented circumstances. Evidence Acquisition: We performed a literature review on the current evidence based on urology residency training during the COVID-19 pandemic. Relevant databases (MEDLINE, Scopus, and Cochrane Library) were searched (until June 2021), and the main inclusion criterion was the presence of residents’ or directors’ opinion on their residency training program during the COVID-19 pandemic. Evidence Synthesis: The search identified 72 articles. A total of 14 studies reporting on more than 2500 residents were eligible for inclusion. The articles were analyzed, and the results are presented in the current review. Conclusions: This unprecedented situation has critically affected urology residency training. A decrease in operation volume, especially those in which residents were directly involved as well as in the majority of academic activities, has been reported by many studies. Furthermore, the COVID-19 pandemic has generated a significant impact on trainees’ mental well-being and lifestyle. On the other hand, the lockdown stressed the opportunity to implement innovative training tools, such as smart training programs and surgical skill development activities monitored by expert urologists.

Simulation in surgical education: resident’s point of view

: Changes in healthcare system, such as implementation of working hours’ restrictions in residency programs, and ethical and patient’s security regulations, have modified the methods and available time for trainee’s education. These restrictions, have motivated the creation of novel teaching tools for a complete and successful education. Currently, simulation is one of the most implemented teaching methods globally. Fortunately, different simulation models have been developed: Virtual simulation, simulation in living animals, human and animal cadavers, box-training simulation, and 3D printed artificial models, among others. Nevertheless, each of these simulation models have their own advantages and disadvantages. Surgical skills development, improvements of perioperative results, decrease in hospital stay, and reduced costs are some advantages associated with simulation. Lack of homogeneous simulation programs, and costs of acquisition and maintenance of the equipment are drawbacks of surgical simulation. Surgical simulation is particularly attractive because it allows trainees to develop surgical skills in a “real-life”, controlled, and safe scenario. This avoids practicing in a clinical environment, which potentially increases patient’s safety, reduces perioperative complications, and decreases costs. In the last decades, surgical simulation has been gaining popularity in most residency programs worldwide, with a protected time for this activity. As a resident, I think that simulation is a great and useful teaching tool that should be part of all surgical residency curriculums.

Job Satisfaction and Intentions to Leave of Foreign-National Urologists Working at German Hospitals: Results of the Cross-Sectional EUTAKD Study

Background: Studies exist that identify factors associated with higher professional satisfaction among clinicians. However, there are no reliable findings for clinicians with a migration background as to whether there is a correlation between particular dimensions of professional satisfaction and the desire to leave their current specialty or country of employment. For the first time, these data were collected within a questionnaire-based study from urological clinicians with a migration background (UCMBs) working in Germany. Material and Methods: A SurveyMonkey® with 101 items relating to characterizing features of the study participants and questions about job satisfaction (n = 39) was opened for UCMBs between August and October 2020. The influence of different dimensions of job satisfaction on the desire to quit the urological specialty/leave Germany was analyzed (group A: neither want to leave urology nor Germany; group B: can at least imagine leaving the urological profession and/or Germany). Results: Eighty-one UCMBs were distributed almost equally in groups A (50.6%) and B (49.4%). Occupational satisfaction was higher in several respects in group A. Three dimensions that differed significantly with regard to occupational satisfaction were used to create an aggregate score ranging from 3 to 15 points as follows: (1) relationship to superiors (p = 0.014), (2) career opportunities in the clinic (p < 0.001), and (3) opportunities for the further development of surgical skills (p = 0.006). For each point value of this aggregate score, the UCMB’s desire to quit urology or leave Germany (or at least uncertainty about this question) decreased by a relative value of 34.6% (odds ratio: 0.654, 95% confidence interval: 0.496–0.861, p = 0.002). Conclusions: Various dimensions of job satisfaction have been identified, the improvement of which could contribute to the long-term retention of UCMBs at German urological clinics.

Impact of the COVID-19 pandemic on surgical skills training in pediatric surgery residents.

PurposeTo analyze the initial impact of the SARS-CoV-2 pandemic on surgical skills training and performance of Pediatric Surgery Residents.MethodsRetrospective study considering the modifications on the Pediatric Surgery Residency training from March 1st–May 31st, 2020. Exposure to OR learning opportunities was compared to the same 2018–2019 trimesters. An anonymous survey about self-perception on surgical skills development was also performed.ResultsResidents performed 209 procedures as leading surgeons during the 2020 trimester with a mean number of surgeries per resident of 20.9, representing a reduction of 46% and 56.8% compared to the 2018–2019 averages, respectively. Reduction in both the number and the percentage of total procedures (n: 209, 56.8%) compared to both 2019 (n: 354, 68.7%, p: 0.000272) and 2018 (n: 420, 76.1%, p < 0,00,001) showed statistical correlation with no changes in their complexity pattern.From the survey (response rate: 100%), hours dedicated to simulation-based training were highly increased. More time was spent studying, but only 60% achieved better preparation for surgery and 70% perceived a decrease in surgical confidence.ConclusionsEven though the pandemic promoted new teaching strategies and the use of simulation-based training, it drastically reduced “on-the-job” learning opportunities with potential effects on residents’ performance and self-confidence during surgery.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00383-021-04961-8.

COVID-19 Restrictions Presented Opportunities and Challenges for Plastic Surgery Residents.

Background:Restrictions placed during the COVID-19 pandemic to prevent viral spread led to substantial changes in surgical resident education. The aim of this study was to assess the positive and negative impact of COVID-19 on plastic surgery education and training and provide recommendations for continued competency.Methods:A cross-sectional online survey of plastic surgery residents across Canada was used to evaluate the impact of COVID-19 on clinical exposure, experience with virtual education, and long-term impact of COVID-19 on surgical training.Results:This study included 61 plastic surgery residents (40% participation rate). Common educational modalities used during COVID-19 included online seminars (95%) and workshops (58%). Teaching sessions were effective if structured around patient cases (72%), recorded (66%), and limited to 1 hour (64%). There were mixed reactions towards online education sessions; residents reported feeling grateful (54%), motivated (38%), enthusiastic (28%), overwhelmed (41%), pressured to participate (23%), and anxious (13%). There were significantly less residents who felt that their clinical exposure was sufficient during (21%) versus before (72%) pandemic restrictions (P < .001). Overall, 87% of residents felt that the pandemic had a negative impact on their training, surgical skill development, fellowship plans, and job prospects.Conclusions:During the initial wave of COVID-19, residents faced altered educational opportunities, which elicited positive and negative emotions with concern regarding surgical skill development and impact on future career plans. Characterizing early educational impact on residency training to identify opportunities for change is worthwhile as the overall effect of the pandemic is ongoing and remains uncertain.

AB061. SOH21AS058. Evaluating the use of a proximal femoral nail module using a virtual reality orthopaedic simulator: a face and construct validity study

Background: Changing surgical practice due to the European Working Time Directive, shorter training times, and novel technological advancements compel current surgical curricula to find innovative methods of training to ensure adequate development and retention of surgical skills in our trainees. Virtual reality simulation as a learning tool to transcend current training methods have been of recent interest. This study aimed to identify the face and construct validity of the Precision OS trauma module proximal femoral nail procedure.

3D printing in surgical simulation: emphasized importance in the COVID-19 pandemic era

3D printing in surgical simulation: emphasized importance in the COVID-19 pandemic era

Low versus high level of physical resemblance in simulation for the acquisition of basic surgical skill: a meta-analysis

BackgroundMany studies explored the use of simulation in basic surgical education, with a variety of devices, contexts and outcomes, with sometimes contradictory results.ObjectivesThe objectives of this meta-analysis were to focus...

Influence of musical background on surgical skills acquisition

BackgroundThere is growing interest in identifying trainees with surgical aptitude predictive of eventual technical proficiency. Musical tasks involve complex, cerebral activity, and ambidextrousity, which may have a positive impact on the acquisition of surgical skill sets. The purpose of this study was to investigate the influence of prior musical experience on the performance of basic surgical skills. MethodsThis was a prospective cross-sectional study involving 51 novice undergraduate and medical school trainees with no prior surgical exposure. Musicality was assessed with a detailed survey and objectively with the Mini-Profile of Music Perception Skills test. Dexterity was assessed using the Purdue Pegboard test. Surgical skills were then evaluated by performing 2 timed suturing trials after observing tutorial video, followed by a timed laparoscopic peg transfer test. Outcomes included both speed and quality of performance. ResultsParticipants with prior musical experience performed better than nonmusicians on the Mini-Profile of Music Perception Skills test (P = .015), dominant hand dexterity (P = .05), suture quality (P < .03), and laparoscopic peg transfer speed (P < .01). There was no significant difference in the suturing speed between musicians and nonmusicians. The dexterity and Mini-Profile of Music Perception Skills scores were predictive of suture quality (P < .01). Among musicians, duration of musical training, inactivity, instrument type, and certification levels did not correlate with differences in surgical task performance. ConclusionMusical background is associated with better performance of fundamental surgical skills among surgical novices, particularly technique quality. Although this does not imply superior ultimate surgical ability, musicality may be a marker for basic surgical skill development useful in identifying suitable candidates for surgical training.

Video Feedback and Video Modeling in Teaching Laparoscopic Surgery: A Visionary Concept from Kiel.

Learning curves for endoscopic surgery are long and flat. Various techniques and methods are now available for surgical endoscopic training, such as pelvitrainers, virtual trainers, and body donor surgery. Video modeling and video feedback are commonly used in professional training. We report, for the first time, the application of video modeling and video feedback for endoscopic training in gynecology. The purpose is to present an innovative method of training. Attendees (residents and specialists) of minimally invasive surgery courses were asked to perform specific tasks, which were video recorded in a multimodular concept. Feedback was given later by an expert at a joint meeting. The attendees were asked to fill a questionnaire in order to assess video feedback given by the expert. The advantages of video feedback and video modeling for the development of surgical skills were given a high rating (median 84%, interquartile ranges (IQR) 72.5–97.5%, n = 37). The question as to whether the attendees would recommend such training was also answered very positively (median 100%, IQR 89.5–100%, n = 37). We noted a clear difference between subjective perception and objective feedback (58%, IQR 40.5–76%, n = 37). Video feedback and video modeling are easy to implement in surgical training setups, and help trainees at all levels of education.

Prefrontal transcranial direct-current stimulation improves early technical skills in surgery

BackgroundStudies applying transcranial direct-current stimulation (tDCS) to motor regions to enhance surgical skills have observed modest benefits in performance. Early surgical skills acquisition is known to be dependent on the prefrontal cortex (PFC) which could be a suitable target for performance enhancement in fields with high cognitive demand. ObjectiveTo assess whether prefrontal tDCS could improve early phases of surgical skill development. MethodsIn a randomized sham-controlled double-blind parallel design, 40 surgical novices performed an open knot-tying task repeated in three blocks; pre-, online- and post-tDCS. During online stimulation, participants were randomized to either active tDCS (2 mA for 15 min) to the prefrontal cortex (anode over F3, cathode over F4) or sham tDCS. Performance score (PS) was computed using a validated algorithm and introspective workload domains were assessed using a SURG-TLX questionnaire. ResultsThere was no difference in demographics or PS between groups prior to receiving tDCS. PS significantly improved from pre-to online- (p < 0.001) and from pre-to post-tDCS (p < 0.001) in the active group only. Following active tDCS, PS was closer to the defined proficiency benchmark and significantly greater compared to sham (p = 0.002). Only the active group reported significantly improved temporal demand scores from pre-to online- (p = 0.004) to post-tDCS (p = 0.002). ConclusionsThis study demonstrates significantly improved early phase surgical-skill acquisition following prefrontal tDCS. Further work is required to determine the underlying neurophysiological mechanisms and whether the benefits observed are retained long-term.

Residents’ Views on the Impact of Robotic Surgery on General Surgery Education

The use of the da Vinci Robot has been fast growing in general surgery in the United States over the past decade. While the financial cost of robot-assisted procedures has been studied, there has been limited research on the educational cost of the robotic approach on general surgery trainees, and their surgical skills. Analysis of anonymous educational survey responses collected from residents, in addition to case logs which were used as a retrospective review for the 5 years preceding the survey. One thousand bed, tertiary care hospital general surgery residency program. Twenty-four enrolled general surgery residents in 2018. There has been a rapid expansion in the use of robotics in general surgery. In 2017 the total number of general surgery cases using the da Vinci robot increased 6 fold over that in 2013 (23 cases in 2013, 136 in 2017), while both open and laparoscopic procedures have witnessed about a 33% drop in the case volume during those years. Almost all residents would prefer a residency program which offers the da Vinci robot for care and training (95%), however, 38% of general surgery residents reported that the presence of robotic-assisted surgery had a "detrimental" effect on their surgical training. Senior residents were more likely to report a "detrimental" effect (56% vs 27%). A third of the residents believe that robotic surgery is impeding their ability to learn open and laparoscopic surgical techniques, and only 25% denied a negative impact. Senior residents are more likely to report this negative impact (67% vs 13%). Reforms in residency curricula need to be in place to accommodate the expansion of the use of the robotic platform in general surgery. A subjective survey of the residents suggests that robotic surgery can potentially impede the development of residents' open and laparoscopic surgical skills.

Tomato shave biopsy training for medical students—A retrospective study

To the Editor: Rising pressure for rapid patient care and changing medicolegal landscapes have created a demand for alternate surgical skills development models.1 Although traditional models are based on animals and cadavers, these models carry the risk of infection and high costs. Tomatoes (Lycopersicon esculentum) are described as a low-cost model with many advantages: availability; a variety of shapes and contours; and the ability to measure biopsy accuracy, breadth, and depth. However, their use has never been evaluated for efficacy.

Combat thoracic surgery in Iraq and Afghanistan: 2002-2016.

Thoracic surgery constitutes 2.5% of surgical procedures performed in theater, but the skills required are increasingly foreign to military surgeons. This study examines thoracic surgical workload in Iraq and Afghanistan to help define surgical training gaps. Retrospective analysis of Department of Defense Trauma Registry for all role 2 (R2) (forward surgical) and role 3 (R3) (theater) military facilities, from January 2002 to May 2016. The 95 thoracic surgical International Classification of Diseases-9th Rev.-Clinical Modification procedure codes were grouped into 10 categories based on anatomy or endoscopy. Select groups were further stratified by type of definitive procedure. Procedure groupings were determined and adjudicated by surgeon subject matter experts. Data analysis used Stata Version 15 (College Station, TX). Of the total procedures, 5,301 were classified as thoracic surgical procedures and were included in the present study. The majority of thoracic surgical procedures (4,645 [87.6%]) were recorded as being performed at R3 medical treatment facilities (MTFs). The thoracic surgical procedures groups with the largest proportions were: bronchoscopy (39.1%), thoracotomy (16.9%), diaphragm (15.6%), and lung (11.4%). The most common lung procedure subgroup, aside from not otherwise specified, was segmentectomy (28.8%). The R3 MTFs recorded nearly five times the number of lung procedures compared with R2 MTFs; with R3 MTFs recording more than eight times the number of lobectomies compared with R2 MTFs. Thoracic workload was variable over the 15-year study period. Thoracic surgical skills are necessary in the deployed environment to manage combat-related injuries. Given the current trends in training and specialization, development and sustainment of thoracic surgical skills is challenging in the deployed US trauma system and likely for other nations, and humanitarian surgical care as well. Current training and practice paradigms pose both training and sustainment challenges for surgeons who deploy to a combat zone. Therapeutic/Care Management IV.