High-fidelity Surgical Simulation Research Articles

Validation of a surgical simulator and establishment of quantitative performance thresholds – RealSpine simulation system for open lumbar decompressions

The majority of surgical training is conducted in real-world operations. High-fidelity surgical simulators may provide a safer environment for surgical training. However, the extent that it reflects real-world operations and surgical ability is often poorly characterized. (1) Assess the validity and fidelity of a surgical simulator; (2) Examine the quantitative relationship between simulation performance and markers of real-world ability; (3) Establish thresholds for surgical expertise, and estimate their external validity and accuracy. A cohort study of surgeons at a British neurosurgical center. 10 early-career "novice" surgeons and 8 board-certified "expert" neurosurgeons. (1) Face and content validity, and visual and haptic fidelity; (2) Construct validity; (3) Predictive and discriminative utility of quantitative performance thresholds. Participants performed unilateral lumbar decompressions on high-fidelity spinal simulators that replicate the bony and soft tissue anatomy along with physiological processes such as bleeding and CSF leaks. Operating times, measured from first surgical action to either self-perceived satisfactory decompression or the end of allocated time, were recorded. The performance was also assessed independently by two blinded spinal subspecialist neurosurgeons using OSATS, a validated surgical assessment tool that utilizes five-point scales on a variety of technical domains to grade the overall technical proficiency. Validity and fidelity were assessed by expert neurosurgeons using quantitative questionnaires. Construct validity was assessed by ordinal regression of simulation performance against real-world surgical grade and portfolio. Thresholds of expert status by simulation performance was established, and their predictive and discriminative utility assessed by crossvalidation accuracy and AUC-ROC. Operating time and expert assessments of simulation performance (OSATS) were strong and significant predictors of surrogate markers of real-world surgical ability. The thresholds for expert status were operating time of 15 minutes and modified OSATS score of 15/20. These thresholds predicted expert status with 84.2% and 71.4% accuracy respectively. Strong discriminative ability was demonstrated by AUC-ROC of 0.95 and 0.83 respectively. All expert surgeons agreed that RealSpine simulators demonstrate high face validity, and high visual and haptic fidelity, with overall scores showing statistically significant agreement on these items (all scores at least 4/5, P<.0001). There was less consensus on content validity, but with still significant overall agreement (average score: 3.75/5, P=0.023). Real-world surgical ability and experience can be accurately predicted by defining objective quantitative thresholds on high-fidelity simulations. The thresholds established here, along with other data presented in this paper, may inform objectives and standards to be established in a spinal surgical training curriculum.

Pilot Validation of a 3-Dimensional Printed Pituitary Adenoma, Vascular Injury, and Cerebrospinal Fluid Leak Surgical Simulator.

Endoscopic skull base surgery is a subspecialty field which would benefit significantly from high-fidelity surgical simulators. Giving trainees the opportunity to flatten their learning curve by practicing a variety of procedures on surgical simulators will inevitably improve patient outcomes. Four neurosurgeons, 8 otolarynologists, and 6 expert course faculty agreed to participate. All participants were asked to perform a transsphenoidal exposure and resection of a pituitary adenoma, repair a cerebrospinal fluid (CSF) leak, control a carotid injury, and repair a skull base defect. The content, face, and construct validity of the 3-dimensional printed model was examined. The heart rate of the participants significantly increased from baseline when starting the carotid injury simulation (mean 90 vs 121, P = .029) and significantly decreased once the injury was controlled (mean 121 vs 110, P = .033, respectively). The participants reported a significant improvement in anxiety in facing a major vascular injury, as well as an increase in their confidence in management of major vascular injury, resecting a pituitary adenoma and repair of a CSF leak using a 5-point Likert scale (mean 4.42 vs 3.58 P = .05, 2 vs 3.25 P < .001, 2.36 vs 4.27 P < .001 and 2.45 vs 4.0 P = .001, respectively). The mean Objective Structured Assessment of Technical Skills score for experienced stations was 4.4, significantly higher than the Objective Structured Assessment of Technical Skills score for inexperienced stations (mean 3.65, P = .016). We have demonstrated for the first time a validated 3-dimensional printed surgical simulator for endoscopic pituitary surgery that allows surgeons to practice a transsphenoidal approach, surgical resection of a pituitary adenoma, repair of a CSF leak in the diaphragma sellae, control of a carotid injury, and repair of skull base defect.

Effect of surgical simulator training on student and live animal outcomes in a feline ovariohysterectomy teaching laboratory.

To evaluate the effect of training with a high-fidelity surgical simulator on outcomes of live animals and students participating in a feline ovariohysterectomy teaching laboratory. Nonrandomized controlled trial. Cats (n = 186) and students (n = 146). Live animals were paired with student surgeons. Outcomes for animals and students were evaluated over two consecutive years before (year 1: NO SIM) and after (year 2: SIM) the introduction of a graded student teaching laboratory conducted on a high fidelity surgical simulator. Live animal surgical times and postoperative pain scores using the Glasgow Composite Measure Pain Scale - Feline acute pain scale as well as self-declared student confidence were assessed and the scores of the two groups were compared. The duration of the live animal surgical procedure was on average 6 min shorter in the SIM group (p = .04). A pain score triggering intervention (> = 5/20) occurred less frequently in the SIM group (n = 1/82) than in the NO-SIM (n = 16/104) group (p < .01). Similarly, rescue analgesia was administered less frequently (4/82 vs 16/104, p = .03) in the SIM group. Student confidence prior to the live animal procedure was higher (median = 7/10 [IQR = 6-8]) in the SIM group than in the NO-SIM group (median = 6/10 [IQR = 4-7]) (p < .01). Surgical simulator training prior to live animal procedures improves live animal outcomes and student confidence. Surgical simulator competency should be considered a prerequisite to participation in live animal teaching laboratories. This would improve both animal welfare and the student experience.

A70Novel high-fidelity Surgical Simulation Educational Program (SSEP) – a systems-based approach for enhanced patient safety

Increased pressures within the NHS, shortened learning hours and disruptions caused by the COVID-19 pandemic has significantly impacted surgical training. Current courses focus on single training levels, but errors occur through systemwide failures [1]. We developed a SSEP targeting cross specialty and team-based patient management, focused on clinical knowledge and skills, cognitive simulation, leadership and human factors based upon real life events to optimize training in a system that lacks time and exposure. A six-month pilot program was designed with monthly sessions, attended by surgical nurses, junior doctors and consultants, covering common surgical scenarios mapped to the ISCP curriculum [2], and topics highlighted through local clinical governance. Immersive interactive sessions were delivered by a dedicated consultant led education team to provide a mixed reality environment for each simulated scenario. Faculty encompassed emergency, anaesthetic and surgical consultants to facilitate realistic multidisciplinary team working. The professional identity and grade of participants were maintained during each simulation to ensure sessions were representative of real-life events with a clear mutual goal to improve knowledge and skills to transpose into safer patient care at all levels of seniority. Sessions combined simulated scenarios with structured teaching, clear learning objectives, detailed peer feedback and opportunity for juniors to complete work-based assessments with consultants. Senior trainees benefited from participation in the design and delivery of sessions providing opportunities to strengthen their leadership skills. We recorded participants pre- and post-simulation confidence, and knowledge, were measured using 5-point Likert scale feedback forms, and multiple-choice questionnaire (MCQ) paper respectively. Two-paired T analysis showed statistically significant improvements in participant confidence across all 4 simulations ( Pooled two-paired T-Test analysis of participant self-rated confidence, in managing clinical scenarios and core topics, before and after participation in 4 high-fidelity simulated scenarios, at the 95% confidence interval (*Significance α = ≤0.05). Our SSEP is an effective strategy for the improvement of trainees’ confidence and knowledge in managing challenging surgical scenarios, which actively contributes to the development of skills for clinical practice. Evaluation of long-term knowledge retention is necessary. Our ambition is to develop the program as a quality improvement project (QIP) that implements learning from significant events and demonstrate improved outcomes in these domains. We endeavour to embed this simulation training across the region. Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

The impact of incorporating surgical simulation into trichiasis surgery training on operative aspects of initial live-training surgeries.

While surgical simulation is regularly used in surgical training in high-income country settings, it is uncommon in low- and middle-income countries, particularly for surgical training that primarily occurs in rural areas. We designed and evaluated a novel surgical simulator for improving trachomatous trichiasis (TT) surgery training, given that trichiasis is mostly found among the poorest individuals in rural areas. TT surgery programs were invited to incorporate surgical simulation with a new, high fidelity, low-cost simulator into their training. Trainees completed standard TT-surgery training following World Health Organization guidelines. A subset of trainees received three hours of supplemental training with the simulator between classroom and live-surgery training. We recorded the time required to complete each surgery and the number of times the trainer intervened to correct surgical steps. Participants completed questionnaires regarding their perceptions. We also assessed trainer and trainee perceptions of surgical simulation training as part of trichiasis surgery training. 22 surgeons completed standard training and 26 completed standard training plus simulation. We observed 1,394 live-training surgeries. Average time to first live-training surgery completion was nearly 20% shorter the simulation versus the standard group (vs 34.4 minutes; p = 0.02). Trainers intervened significantly fewer times during initial live-training surgeries in the simulation group (2.7 vs. 4.8; p = 0.005). All trainers indicated the simulator significantly improved training by allowing trainees to practice safely and to identify problem areas before performing live-training surgeries. Trainees reported that simulation practice improved their confidence and skills prior to performing live-training surgeries. A single high-fidelity surgical simulation session can significantly improve critical aspects of initial TT surgeries.

Surgical Simulation of Posterior Sagittal Anorectoplasty for Rectovestibular Fistula: Low-Cost High-Fidelity Animal-Tissue Model

PurposeTo provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of a Posterior Sagittal Anorectoplasty (PSARP) for rectovestibular fistula in anorectal malformation (ARM). Materials and methodsA chicken cadaver was used to assess the feasibility of simulating a PSARP for rectovestibular fistula in ARM. No modification was required to implement the surgical simulation. ResultsA detailed description of the high-fidelity surgical simulation model is provided. The PSARP can be simulated while providing realistic anatomy (e.g. common wall between rectovestibular fistula and vagina), adequate rectal size, location and placement of the rectovestibular fistula, and proximity to the vagina. Haptic conditions of the tissue resemble human tissue and operative conditions as well. DiscussionConcerning the decreased exposure of index cases of pediatric surgical trainees and pediatric surgeons in practice, simulation-based training can provide means to acquire or maintain the necessary skills to perform complex surgical procedures [1–5]Surgical simulation models for ARM are limited. Few low-cost trainers are available with predominant artificial and mostly unrealistic tissue [6–8] Animal models have the advantage of realistic multilayer tissue haptic feedback [6]. ConclusionWe provide a low-cost, high-fidelity model for correcting a rectovestibular fistula in a child with ARM, a complex operative procedure with low incidence but high-stake outcomes. The described tissue model utilizing the chicken cloaca anatomy provides a high-fidelity model for operative correction of rectovestibular ARM. For simulation purposes in the treatment of ARM, this model appears to be promising in terms of providing realistic pathology and haptic feedback in pediatric dimensions. Level of evidenceV.

Future Directions for Global Clinical Neurosurgical Training: Challenges and Opportunities

Expanded access to training opportunities is necessary to address 5 million essential neurosurgical cases not performed annually, nearly all in low- and middle-income countries. To target this critical neurosurgical workforce issue and advance positive collaborations, a summit (Global Neurosurgery 2019: A Practical Symposium) was designed to assemble stakeholders in global neurosurgical clinical education to discuss innovative platforms for clinical neurosurgery fellowships. The Global Neurosurgery Education Summit was held in November 2021, with 30 presentations from directors and trainees in existing global neurosurgical clinical fellowships. Presenters were selected based on chain referral sampling from suggestions made primarily from young neurosurgeons in low- and middle-income countries. Presentations focused on the perspectives of hosts, local champions, and trainees on clinical global neurosurgery fellowships and virtual learning resources. This conference sought to identify factors for success in overcoming barriers to improving access, equity, throughput, and quality of clinical global neurosurgery fellowships. A preconference survey was disseminated to attendees. Presentations included in-country training courses, twinning programs, provision of surgical laboratories and resources, existing virtual educational resources, and virtual teaching technologies, with reference to their applicability to hybrid training fellowships. Virtual learning resources developed during the coronavirus disease 2019 pandemic and high-fidelity surgical simulators were presented, some for the first time to this audience. The summit provided a forum for discussion of challenges and opportunities for developing a collaborative consortium capable of designing a pilot program for efficient, sustainable, accessible, and affordable clinical neurosurgery fellowship models for the future.

Integration of Reinforcement Learning in a Virtual Robotic Surgical Simulation.

Background. The revolutions in AI hold tremendous capacity to augment human achievements in surgery, but robust integration of deep learning algorithms with high-fidelity surgical simulation remains a challenge. We present a novel application of reinforcement learning (RL) for automating surgical maneuvers in a graphical simulation.Methods. In the Unity3D game engine, the Machine Learning-Agents package was integrated with the NVIDIA FleX particle simulator for developing autonomously behaving RL-trained scissors. Proximal Policy Optimization (PPO) was used to reward movements and desired behavior such as movement along desired trajectory and optimized cutting maneuvers along the deformable tissue-like object. Constant and proportional reward functions were tested, and TensorFlow analytics was used to informed hyperparameter tuning and evaluate performance.Results. RL-trained scissors reliably manipulated the rendered tissue that was simulated with soft-tissue properties. A desirable trajectory of the autonomously behaving scissors was achieved along 1 axis. Proportional rewards performed better compared to constant rewards. Cumulative reward and PPO metrics did not consistently improve across RL-trained scissors in the setting for movement across 2 axes (horizontal and depth).Conclusion. Game engines hold promising potential for the design and implementation of RL-based solutions to simulated surgical subtasks. Task completion was sufficiently achieved in one-dimensional movement in simulations with and without tissue-rendering. Further work is needed to optimize network architecture and parameter tuning for increasing complexity.

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

Development of a Surgical Video Atlas for Resident Education: 3-Year Experience.

ObjectiveTo create a high-quality annotated online surgical video atlas of key indicator otolaryngology cases and assess its use and overall journal trends over time.MethodsVideos are recorded from multiple viewpoints within the operating room and compiled into a single stream. Postediting includes chaptering videos and overlaying relevant text annotations. Videos are published online and viewership trends analyzed.ResultsOver 3 years, 29 otolaryngology videos were published out of 161 journal publications (18%). Eight of the 14 key indicator procedures are included (57%). From the beginning of 2017 to the end of 2019, viewership of otolaryngology pages increased from 548 to 11,139 views per month, totaling >150,000 views. These now represent 10% of the total journal monthly views and 10% of the overall views. Users originate from the United States and from >10 other countries.DiscussionResidents and faculty face challenges of providing the highest standard of clinical care, teaching, and learning in and out of the operating room. Inherent difficulties of surgical training, high-fidelity surgical simulation, and imposed work hour restrictions necessitate additional, more efficient and effective means of teaching and learning. Surgical videos demonstrating key anatomy, procedural steps, and surgical dexterity with hand positioning are increasing in their popularity among learners.Implications for PracticeSurgical video atlases provide a unique adjunct for resident education. They are enduring and easily accessible. In a climate of work hour restrictions or elective case reduction, they may supplement how residents learn to operate outside the operating theater.

CADAVERIC ECMO CANNULATION SIMULATOR

Extracorporeal cardiopulmonary resuscitation (ECPR) is a high stakes low opportunity event which involves cannulating and initiating ECMO support in the arresting patient. In response to recent evidence suggesting ECPR can drastically improve neurologic outcome for refractory cardiac arrest, this technology is more frequently being employed in the emergency department for out of hospital arrests. 1-2 Optimal initiation of ECMO in this setting requires the cooperation of multiple team members with varied backgrounds. This is best facilitated by education and deliberate practice via simulation activity. 1-2 At our institution, simulation with a perfusion-capable mannequin has been used to provide realistic training in areas of crisis resource management related to ECPR, however, the actual technical aspects of cannulation are difficult to simulate. The Dalhousie University Clinical Cadaver Program provides soft-preserved cadavers for high fidelity surgical and technical simulation. While clinical cadavers have been used previously for endovascular procedural training 3-4, we present the first simple novel perfused model capable of realistic venous and arterial ECMO cannulation. All four limbs were secured with trauma tourniquets to maintain fluid within the central vasculature. The right carotid artery and internal jugular vein were accessed through cutdown. Pursestrings were placed on each vessel. The carotid was cannulated with an 8 Fr central venous catheter. An 18 Fr Coude catheter was introduced through the IJ, directed past the right atrium and into the inferior vena cava. Positioning was confirmed with ultrasound. NS was infused under pressure into the arterial and venous systems of the cadaver and femoral cannulation was attempted by physicians with experience in ECPR cannulation. The video shows that the model demonstrated realistic ultrasound images of the femoral artery and vein for cannulation. Fluid remained within the central vasculature long enough to facilitate ultrasound guided cannulation. We were successfully able to introduce arterial and venous cannulas. We demonstrate a perfused cadaver model that provides a realistic cannulation simulation and can be prepared relatively easily. Successful ECPR Programs will require trained physicians who are available to perform this infrequent but technically demanding procedure. Our model could be used to provide training to those physicians. Additionally, our model could be used by Cardiac Surgery Training Programs for simulation of cannulation of other areas.

Development of a high fidelity subglottic stenosis simulator for laryngotracheal reconstruction rehearsal using 3D printing

IntroductionLaryngotracheal reconstruction (LTR) with cartilage graft augmentation is an effective treatment for subglottic stenosis and a critical advanced procedure for Pediatric Otolaryngologists. Trainees almost exclusively learn this procedure intraoperatively on children due to the lack of adequate pediatric training models. An enhanced and accelerated educational experience may be possible if trainees can rehearse the key portions of the procedure on a simulation model. ObjectiveTo design and manufacture a low-cost, high fidelity surgical simulation model of subglottic stenosis for LTR. MethodsThis simulator is composed of two component models: rib cartilage and trachea. Additive manufacturing techniques, including Computer Aided Design and Three Dimensional (3D) printing, were utilized to create the simulator. Three expert Pediatric Otolaryngologists rated the functionality and realism of the simulator using Likert scale survey data. ResultsThe use of CAD and 3D printing techniques allowed for realistic, reproducible surgical simulation of key aspects of LTR. The validation evidence indicated good to excellent means across the five domains relevant to the simulator's fidelity and usability (M = 3.47 to 4.00) out of a maximum of 4 points. Lowest rated items were consistent with expert comments suggesting minor simulator improvements. Time of production is approximately 20 h from print to post-processing, and consumable material costs per model are $2.60 USD. ConclusionsThis subglottic stenosis airway simulator facilitated Laryngotracheal Reconstruction rehearsal and is a promising training tool for pediatric otolaryngologists. Our methods allow patient-specific, pre-surgical rehearsal for complex airway scenarios that could benefit the experienced airway surgeon and trainees alike. Future research aims to validate this device's utility for accelerating attainment of proficiency and improving surgical outcomes.

Feasibility of a New Wearable Device to Estimate Acute Stress in Novices During High-fidelity Surgical Simulation.

Stress associated with learning of a psychomotor task can influence the trainees learning ability. Surgical simulation is a validated training milieu designed to replicate real-life situations, prevent biases and provide objective metrics. However, the complexity of stress mechanisms and the absence of a reliable detection method make stress estimation difficult to quantify and to interpret. a) To assess the feasibility of a new watch-sized device to noninvasively measure stress parameters in novices during a simulation task and b) to compare its derived cardiac stress parameters to those of an ambulatory Holter monitor. Twenty-one novices were trained on a basic skills module. During base line, exercise, and recovery phases, all subjects wore a wearable device and data regarding blood volume pressure, heart rate, inter beat interval, electrodermal activity, and skin temperature were recorded. Additionally, Holter Monitoring was used to concomitantly capture heart rate, R-R intervals and heart rate variability. Before and after each experiment, all subjects completed the short, six-item STAI scale. Data analysis showed: a) when compared to STAI, electrodermal activity exhibited the best correlation, sensitivity and specificity and b) the device derived cardiac parameters highly correlated with the reciprocal Holter values during all experiment phases. This wearable device is an easy to use and well accepted by the participants noninvasive tool, which can provide accurate stress estimation in our simulation setting. Additionally, it can replicate Holter derived stress related heart parameters, thus eliminating the need to wear a rather cumbersome device.

Discussion: The Skoog Lip Repair for Unilateral Cleft Lip Deformity: The Uppsala Experience.

Toronto, Ontario, Canada From the University of Toronto and the Cleft Lip and Palate Program, The Hospital for Sick Children. Received for publication February 12, 2018; accepted February 13, 2018. Disclosure:Dr. Fisher is a cofounder of and consultant to Simulare, a small start-up company dedicated to the production of high-fidelity surgical simulators. David M. Fisher, F.R.C.S.C., The Hospital for Sick Children, 5424-555 University Avenue, Toronto, Ontario, Canada M5G 1X8, [email protected]

Can Robots Accelerate the Learning Curve for Surgical Training? An Analysis of Residents and Medical Students

Surgical traineeship has traditionally been based on a master apprentice model where learning takes place in the operating theatre. This approach has changed over the past few years with greater emphasis on surgical training taking place within the surgical skills laboratory. We developed a high fidelity simulator, the Image-guided Robotic Assisted Surgical simulator (IRAS) with an incorporated robotic guidance feature. The robot system is developed to mimic the process of an experienced surgeon physically holding a trainee's hands to demonstrate maneuvering of the laparoscopic instruments. We aimed to assess the efficacy of incorporating robotic guidance into this high fidelity surgical simulator. Forty-two participants (13 surgical residents and 29 medical students) were recruited. Participants had one practice run for familiarisation and subsequently performed the virtual laparoscopic cholecystectomy (LC) once. Among the medical students, they were ransomised to either a control or intervention group. They were tasked to perform a second- and third-timed LC assessment. Participants were asked to rate the simulator using a 5-point Likert scale Questionnaire. IRAS rated favourably in hand-eye coordination and training bimanual dexterity (mean score: 4.1 and 4.0 among students, 3.4 and 3.4 among residents) though it faired suboptimally in realism. At baseline, residents were statistically faster compared to students (overall time: 418.9 vs 586.8 seconds, P = 0.001). Participants randomised to the intervention group consistently scored better. However, their overall time were not statistically significant from the control group. The robotic guidance capability of the IRAS is a key advantage of this simulator platform over the conventional platform.

Non-Invasive Acute Stress Estimation In Novices During High-Fidelity Surgical Simulation

Journal of the American College of Surgeons 225(4):p e156, October 2017. | DOI: 10.1016/j.jamcollsurg.2017.07.950

Damage control surgery in weightlessness

Torso bleeding remains the most preventable cause of post-traumatic death worldwide. Remote damage control resuscitation (RDCR) endeavours to rescue the most catastrophically injured, but has not focused on prehospital surgical torso hemorrhage control (HC). We examined the logistics and metrics of intraperitoneal packing in weightlessness in Parabolic flight (0g) compared to terrestrial gravity (1g) as an extreme example of surgical RDCR. A surgical simulator was customized with high-fidelity intraperitoneal anatomy, a "blood" pump and flowmeter. A standardized HC task was to explore the simulator, identify "bleeding" from a previously unknown liver injury perfused at 80 mm Hg, and pack to gain hemostasis. Ten surgeons performed RDCR laparotomies onboard a research aircraft, first in 1g followed by 0g. The standardized laparotomy was sectioned into 20-second segments to conduct and facilitate parabolic flight comparisons, with "blood" pumped only during these time segments. A maximum of 12 segments permitted for each laparotomy. All 10 surgeons successfully performed HC in both 1g and 0g. There was no difference in blood loss between 1g and 0g (p = 0.161) or during observation following HC (p = 0.944). Compared to 1g, identification of bleeding in 0g incurred less "blood" loss (p = 0.032). Overall surgeons rated their personal performance and relative difficulty of surgery in 0g as "harder" (median Likert, 2/5). However, conducting all phases of HC were rated equivalent between 1g and 0g (median Likert, 3/5), except for instrument control (rated slightly harder, 2.75/5). Performing laparotomies with packing of a simulated torso hemorrhage in a high-fidelity surgical simulator was feasible onboard a research aircraft in both normal and weightless conditions. Despite being subjectively "harder," most phases of operative intervention were rated equivalently, with no statistical difference in "blood" loss in weightlessness. Direct operative control of torso hemorrhage is theoretically possible in extreme environments if logistics are provided.

Utility of a Cesarean Delivery Surgical Skills Simulation Session for Family Medicine Residents Pursuing Surgical Obstetrics Training

BACKGROUND: Family medicine residents pursuing surgical obstetrics training face the challenge of limited opportunities for intraoperative experience during their formal training. The utility of both low and high fidelity surgical simulation models have been demonstrated to increase technical skill development. Obstetrical emergencies have been taught to family medicine utilizing simulation, but have not included cesarean delivery. METHODS: Family medicine residents enrolled in the surgical obstetrics tract underwent a cesarean delivery surgical simulation session. Surgical performance evaluations were obtained from live surgeries performed immediately before and after the simulation session utilizing a previously validated global rating score. De-identified surgical evaluations were used for statistical analysis. Unpaired T test was performed to assess for statistical difference in pre-session and post session scores. RESULTS: Seven residents participated in the simulation session. Fourteen surgical evaluations were completed before the session; 9 evaluations were completed after the session. Global rating scores increased from 21.5 (±0.66) to 28.2 (±0.84), reaching statistical significance (P=.008). All subcomponent scores increased, with tissue respect, time and motion, instrument handling, flow, assistance usage, and procedural knowledge reaching statistical significance. DISCUSSION: A single simulation session utilizing a low fidelity model did show statistical improvement in global surgical skill ratings and its subcomponents.

3D-printed pediatric endoscopic ear surgery simulator for surgical training

IntroductionSurgical simulators are designed to improve operative skills and patient safety. Transcanal Endoscopic Ear Surgery (TEES) is a relatively new surgical approach with a slow learning curve due to one-handed dissection. A reusable and customizable 3-dimensional (3D)-printed endoscopic ear surgery simulator may facilitate the development of surgical skills with high fidelity and low cost. Herein, we aim to design, fabricate, and test a low-cost and reusable 3D-printed TEES simulator. MethodsThe TEES simulator was designed in computer-aided design (CAD) software using anatomic measurements taken from anthropometric studies. Cross sections from external auditory canal samples were traced as vectors and serially combined into a mesh construct. A modified tympanic cavity with a modular testing platform for simulator tasks was incorporated. Components were fabricated using calcium sulfate hemihydrate powder and multiple colored infiltrants via a commercial inkjet 3D-printing service. ResultsAll components of a left-sided ear were printed to scale. Six right-handed trainees completed three trials each. Mean trial time (n = 3) ranged from 23.03 to 62.77 s using the dominant hand for all dissection. Statistically significant differences between first and last completion time with the dominant hand (p < 0.05) and average completion time for junior and senior residents (p < 0.05) suggest construct validity. ConclusionsA 3D-printed simulator is feasible for TEES simulation. Otolaryngology training programs with access to a 3D printer may readily fabricate a TEES simulator, resulting in inexpensive yet high-fidelity surgical simulation.

Resident Performance Assessment: A Crucial Area for Development

Plastic surgery resident assessment has become the next element in resident education that must be developed. Reliable, comprehensive resident evaluation is currently difficult to achieve because of inconsistent assessor participation and an incomplete assessment toolbox. Recent advances in technology may be able to help, but they require judicious application. In particular, attention should be paid to assessing all levels of competence. Miller’s pyramid of assessment can help guide the process.1 The foundation of the pyramid is assessment of what a resident “knows.” Multiple choice or short answer examinations are a familiar tool that evaluates a resident’s medical knowledge. Smart phone applications and the online Plastic Surgery Education Network are an improvement over the older paper exams in which they provide both content and continuous assessment of knowledge and immediate feedback. Residents are able to test themselves at their own pace whereas teachers can monitor their progress and provide tailored education based on demonstrated need. The next level up on the pyramid is assessing what a resident “knows how” to do. Oral examinations do a good job of eliciting a plastic surgery resident’s knowledge of how to deliver good patient care or operate. The cognitive aspects of surgery can also be tested by computer simulators, drawing, and scripting. A resident’s ability to draw a procedure correlates well with the ability to perform the procedure. A resident’s operative script gives insight into the ability to plan and adapt, and the script serves as a permanent technical manual for the resident to revise over the course of a career. Overall, plastic surgery has adequate tools to assess the first 2 levels of the pyramid. The challenge lies in assessing the next 2 levels, particularly in the operating room. The third level of the assessment pyramid has the resident “show how.” In the clinic, standardized patients or simulated scenarios provide a safe way of allowing a resident to demonstrate a required competence before engaging with a real patient. For the operating room, surgical skills labs with cadavers or animal models and both low and high fidelity surgical simulators are excellent assessment tools. Particularly important is the ability of these tools to both teach and provide meaningful feedback in a way that does not put a patient at risk. The top of Miller’s pyramid is “does,” assessing a resident treating a real patient in the clinic or operating room. Portable sport cameras, stationary video cameras, and in-line recording of microsurgery allow direct, valid assessment of a resident’s ability to manage a patient or perform a surgical technique when filtered through the Objective Structured Clinical Examination or Objective Structured Assessment of Technical Skills rubrics available on the American Council for Graduate Medical Education website. Smart phone applications that allow for immediate intake and recording of an operative assessment can increase assessor participation, but in the end, technology cannot eliminate the need for an experienced surgeon to be the ultimate resident assessor.