Learning Of Surgical Skills Research Articles

Does error feedback improve the learning of a simple surgical skill?

The European Working Time regulations (EWTr) have led to a decrease in training opportunities for surgical trainees in the uk. it is therefore imperative that effciency of training is optimised to enable trainees to attain procedural competence within their curtailed training period. Workplace-based assessments are central to the intercollegiate Surgical curriculum Programme. These tools are important as not only do they give a formal way of assessing the trainee but they also trigger formal feedback of performance. The importance of feedback in learning surgical skills has been highlighted for procedures ranging from simple subcuticular suturing 1 and knot tying 2 to more complex vascular anastomoses 3 and laparoscopic work. 4 lack of feedback has been shown previously to have a detrimental effect on learning. 5

Evaluation of a blended learning surgical skills course for rural surgeons

BackgroundRural surgeons have unique learning needs not easily met by traditional continuing medical education courses. MethodsA multidisciplinary team developed and implemented a skills curriculum focused on leadership and communication, advanced endoscopy, emergency urology, emergency gynecology, facial plastic surgery, ultrasound, and management of fingertip amputations. ResultsTwenty-five of 30 (89%) rural surgeons who completed a follow-up course evaluation reported that the knowledge acquired during the course had improved their practice and/or the quality of patient care, particularly by refining commonly used skills and expanding the care options they could offer to their patients. The surgeons reported incorporating changes in their communication and interaction with colleagues. ConclusionsThis course was successful, from participants' perspectives, in providing hands-on mentored training for a variety of skills that reflect the broad scope of practice of surgeons in rural areas. Attendees felt that their participation resulted in important behavior and practice changes.

An affordable model for endolaryngeal phonomicrosurgery: Chicken wings and foam pipe insulation tube

INTRODUCTION Surgical models and phantoms are widely used in medical training, especially in ultrasound-guided interventions or surgical training such as laparoscopic skills. Time spent using phantoms leads to improvements in confidence and success rate. There are numerous articles describing different models or simulators for learning and improvement of ear, nose, and throat surgical skills. These include models for endoscopic sinus and skull base surgery, myringotomy and insertion of tympanostomy tubes, ear surgery simulators, and even a trainer for ligating the lower tonsillar pole. Several models for laryngeal microsurgery have been presented. These include laryngeal dissection stations using cadaveric larynges, animal larynges, or synthetic larynges. A summary of models designed for endolaryngeal microsurgical training is presented in Table I. In this article we present an inexpensive, easy-touse, and feasible laryngeal model based on chicken wings and polyethylene foam-pipe insulation tube.

The Role of Simulation in the Learning of Surgical Skills

Many authors have published theories regarding the learning of practical (surgical) skills. Table 1 contains a useful summary of these theories. Simulation has been defined by Allery et al as 'a structured activity designed to reflect reality, real life and real situations',1 and good simulation has been defined by Gorman et al as 'represent [ing] simplified reality, free from the need to include every possible detail'.2 when discussing simulation in education, issenberg, et al stated: 'Simulations are not identical to real-life events. Instead simulations place trainees into lifelike situations that provide immediate feedback about questions, decisions and actions.'3

Using simulation to improve the cognitive and psychomotor skills of novice students in advanced laparoscopic surgery: A meta-analysis

Advances in simulation technologies have enhanced the ability to introduce the teaching and learning of laparoscopic surgical skills to novice students. In this meta-analysis, a total of 18 randomized controlled studies were identified that specifically looked at training novices in comparison with a control group as it pertains to knowledge retention, time to completion and suturing and knotting skills. The combined random-effect sizes (ESs) showed that novice students who trained on laparoscopic simulators have considerably developed better laparoscopic suturing and knot tying skills (d = 1.96, p < 0.01), conducted fewer errors (d = 2.13, p < 0.01), retained more knowledge (d = 1.57, p < 0.01) than their respective control groups, and were significantly faster on time to completion (d = 1.98, p < 0.01). As illustrated in corresponding Forest plots, the majority of the primary study outcomes included in this meta-analysis show statistically significant support (p < 0.05) for the use of laparoscopic simulators for novice student training on both knowledge and advanced surgical skill development (28 of 35 outcomes, 80%). The findings of this meta-analysis support strongly the use of simulators for teaching laparoscopic surgery skills to novice students in surgical residency programs.

Simulation in surgical education.

The pedagogical approach to surgical training has changed significantly over the past few decades. No longer are surgical skills solely acquired through a traditional apprenticeship model of training. The acquisition of many technical and nontechnical skills is moving from the operating room to the surgical skills laboratory through the use of simulation. Many platforms exist for the learning and assessment of surgical skills. In this article, the authors provide a broad overview of some of the currently available surgical simulation modalities including bench-top models, laparoscopic simulators, simulation for new surgical technologies, and simulation for nontechnical surgical skills.

Organic bench model to complement the teaching and learning on basic surgical skills

To propose an organic bench model made with fruits/vegetables as an alternative to complement the arsenal of simulators used in the teaching and learning of basic surgical skills during medical graduation and education. They were described the training strategies, through the use of fruits (or vegetables) to the learning of different techniques of incision, sutures, biopsies and basic principles of reconstruction. The preparation of bench model, the processes of skill acquisition, feedback and evaluation were also delineated. A proposal for teaching based on an organic model with training delivered in multiple sessions, with increasing levels of difficulty, and with feedback and evaluation during all the process was structured. The organic model, being simple, versatile, portable, reproducible, readily available, and having low cost, is another option to complement the existing simulators for teaching and learning of basic surgical skills.

Simulation Training in Surgery

Surgical training consists of developing cognitive, clinical, and technical skills. Current surgical training in the USA is based on the German-style residency training system introduced by Sir William Halsted at Johns Hopkins Hospital in 1889, with an emphasis on graded responsibility, in which the surgical technical skills in the resident programs were traditionally acquired through mentoring. 1 However, recent advances in minimally invasive surgical technology, educational and motor skill learning theory, and mounting pressures in the clinical environment have raised questions about the reliance on this approach to teaching technical skills in the young generation of surgeons. Therefore, replication of surgical situations through biological models, such as animals and human cadavers, and more recently, the development of nonbiological simulators housed in training laboratories or centers, have been developed. 2 Development of Simulation Training in Surgery

Evaluation of the expectations, learning and competencies of surgical skills by undergraduate veterinary students performing canine ovariohysterectomies

To investigate the development of surgical skills of veterinary undergraduates and determine the number of canine ovariohysterectomies required to achieve competency and reduce levels of student concern. This was compared to student expectations and that of employers regarding surgical ability and provision of support to new graduates. A questionnaire regarding surgical concerns was sent to final year veterinary students enrolled within the University of Bristol, UK. A questionnaire was also sent to 200 UK veterinary practices regarding their impressions of surgical competence of new graduates and their provision of supervision. The responses were compared. Eleven additional final year students performed five canine ovariohysterectomies and graded their concerns. The number of supervised canine ovariohysterectomies required until competency was determined. 80·4% of final year veterinary undergraduates replied that the surgical procedure which they were most concerned about their ability to perform was canine ovariohysterectomy. Students and veterinary practitioners differed in their opinions regarding whether they considered canine ovariohysterectomy to be a "day one skill" and what were desirable levels of supervision. Completing a minimum of four canine ovariohysterectomies led to 81·8% of students being assessed as competent. An unrealistically high expectation of competency by students may be a source of stress and concern. Employers should aim to provide hands-on support whilst new graduates complete at least four canine ovariohysterectomies. Postoperative haemorrhage is uncommon but is the main concern for students.

Surgical Management of Ureteral Injury: A Simulation Training Model

To demonstrate an educational tool that can be used for teaching and learning surgical skills for ureteroureterostomy and ureteroneocystostomy techniques. Description: Although 75% of injuries to the lower urinary tract occur during gynecological procedures, gynecology trainees rarely have an opportunity to learn the skills needed to manage ureteral injury. This video demonstrates the design of a simulator that may be used as a supplement to the training of gynecology and urology trainees and may be used to practice key skills required for performing open and robotic-assisted ureteroureterostomy and ureteroneocystostomy.

Assessing the Surgical Skills of Urology Residents After Preurology General Surgery Training: The Surgical Skills Learning Needs of New Urology Residents

Resident work-hour restrictions and a reduction in general surgery training have impacted urologic training. We sought to assess the educational needs of urology residents after preurology training in general surgery to compare self-reported outcomes to those of supervising faculty and to determine which aspects of preurology training have an impact on those needs. A survey was distributed electronically to urology residents and faculty of Accreditation Council for Graduate Medical Education (ACGME) residency programs. Residents evaluated 11 surgical skills with regard to their importance to subsequent urology training and their self-assessed proficiency with those skills. Faculty members evaluated the same skills with regard to their importance and their residents' proficiency with those skills. All individuals evaluated 11 general surgery rotations with regard to their importance to later urology training. The responses were analyzed using the paired Wilcoxon test, and faculty responses were compared with resident responses using the Fisher exact test and the χ(2)-test. Urologic surgery residency programs in the United States. There were 305 resident responses and 58 faculty responses. For each surgical skill, residents perceived skills as being more important than their self-assessed proficiency with those skills (p < 0.001). Resident and faculty assessments of surgical skills and of general surgery rotations were similar. More time spent in general surgery training was associated with increased self-assessed proficiency. No difference was found between resident and faculty assessment of global surgical skills (p = 0.76) or general surgery rotation importance (p = 0.87). A discrepancy was determined between urology residents' perceptions of the importance of surgical skills and their proficiency with those skills. The duration of general surgery training might have an impact on self-assessed skills proficiency. Concordance was demonstrated between resident and faculty perceptions of residents' surgical skills and of general surgery rotations.

Online Spaced Education Generates Transfer and Improves Long-Term Retention of Diagnostic Skills: A Randomized Controlled Trial

Retention of learning from surgical training is often limited, especially if the knowledge and skills are used infrequently. Using histopathology diagnostic skills as an experimental system, we compared knowledge transfer and retention between bolus Web-based teaching (WBT) modules and online spaced education, a novel email-based method of online education founded on the spacing effect. All US urology residents were eligible to participate. Enrollees were randomized to 1 of 2 cohorts. Cohort 1 residents received 3 cycles/repetitions of spaced education on prostate-testis histopathology (weeks 1 to 16) and 3 WBT modules on bladder-kidney (weeks 14 to 16). Cohort 2 residents received 3 cycles of spaced education on bladder-kidney (weeks 1 to 16) and 3 WBT modules on prostate-testis (weeks 14 to 16). Each daily spaced education email presented a clinical scenario with histopathology image and asked for a diagnosis. Participants received immediate feedback after submitting their answers. Each cycle/repetition was 4 weeks long and consisted of 20 questions with unique images. WBT used the identical content and delivery system, with questions aggregated into three 20-question modules. Long-term retention of all 4 topics was assessed during weeks 18 to 45. Seven-hundred and twenty-four urology residents enrolled. Spaced education and WBT were completed by 77% and 66% of residents, respectively. Spaced education and WBT generated mean long-term score increases of 15.2% (SD 15.3%) and 3.4% (SD 16.3%), respectively (p < 0.01). Spaced education increased long-term learning efficiency 4-fold. Online spaced education generates transfer of histopathology diagnostic skills and substantially improves their long-term retention. Additional research is needed to determine how spaced education can optimize learning, transfer, and retention of surgical skills.

Tip/Trick 1

OBJECTIVES: To determine the effect of self-directed skill practice with weekly verbal feedback sessions for learning basic open and laparoscopic surgical skills in first year Obstetrics and Gynecology (OBGYN) residents. MATERIALS AND METHODS: First year OBGYN residents entering in July 2009 received a study guide consisting of five learning modules: instrument identification, suturing, knot tying, basic laparoscopic skills, and advanced laparoscopic skills. Each module contained 1) a learning map with prerequisite knowledge and skills, unit contents, and criterion-referenced learning objectives that trainees were expected to meet by the end of the training period, and 2) principles of technique, common errors, and prevention strategies. Each resident was given a take-home skills training box that included: suturing and knot tying boards, a portable laparoscopy training box, and videos. In addition to home training, residents attended 4 weekly practice sessions for 60 min/session. Assessments occurred at baseline and 6 weeks after starting the curriculum in knowledge of surgical instruments and skill performing open suturing, knot tying, and Fundamentals of Laparoscopic Surgery (FLS) tasks including peg transfer, cutting, intracorporeal, and extracorporeal knot tying. These tasks are mandatory skills for graduating general surgery residents. The primary outcome was resident performance using global rating scale (GRS) scores and FLS expert-derived cutoff time criteria. RESULTS: All 7 first year residents participated. Median non-supervised practice time was 125 (98–158) minutes per week. Basic instrument identification improved from 6 (18%) to 29 (85%) instruments (P < .001). Residents' performance significantly improved from baseline to posttest in 10/13 skills including: simple interrupted [GRS score = 1 (0–1) to 4 (2–4) P < .01] simple running [1 (1–2) to 3 (1–4) P < .03], and simple subcuticular suture [1 (0–2) to 3 (2–4) P < .03]; instrument handling while suturing [1 (0–2) to 3 (3–4) P < .03]; one-handed square knot at depth [0 (0–2) to 3 (0–4) P < .03]; laparoscopic peg transfer [192s (±52) to 70s (±40) P = .003]; cutting [233s (±64) to 103s (±25) P = .006]; intracorporeal suturing [300s to 166s (±70) P = .005] and extracorporeal suturing [300s to 153s (±46) P < .001]. All residents reached competence cutoff scores in suturing and instrument handling while 71% reached competence in knot tying and efficiency of movement. Two first year residents were able to successfully perform laparoscopic peg transfer and intracorporeal suturing within cutoff times while 3 were able to successfully perform laparoscopic cutting and extracorporeal suturing within cutoff times. On average, trainees reported being 60% (50–100) better than before they started the curriculum. The majority (86%) of residents reported they would recommend continuing the curriculum for learning surgical skills in their residency, while 7/7 (100%) recommended this curriculum to future incoming first year residents. CONCLUSION: Self-directed skill practice with weekly feedback sessions improves formal basic and advanced surgical skill learning in first year residents.

Development of a training curriculum for microsurgery

Recent changes in healthcare necessitate revision of the current apprenticeship model of surgical training. Current methods of assessment such as examinations and logbooks are not criteria-based, so are subjective and lack validity and reliability. The objective feedback of technical skills is crucial to the structured learning of surgical skills. We review current publications about training and methods of assessment in microsurgery. Searches on PubMed using keywords (microsurgery, training, assessment, simulation, and skill) were used to retrieve relevant articles, and further cross-referencing was done to obtain more information. New methods of assessment that are objective include checklists, global rating scales (GRS), and dexterity analysis, which give feedback of technical skills during training. Vital (living), non-vital, prosthetic, and virtual reality simulation models can be used to train surgeons to a proficient level outside the operating theatre before they operate on real patients. After reviewing the current evidence we propose a curriculum for microsurgical training that starts outside the operating theatre. The surgical community should follow the example of other high-risk industries such as aviation, where continuous assessment on simulators is a part of training, but further research is necessary before such methods can be used for summative assessment and revalidation.

The frontal cortex is activated during learning of endoscopic procedures

To date, several training and evaluation systems for endoscopic surgery have been developed, such as virtual-reality simulators and box trainers. However, despite current advances in these objective assessments, no functional brain studies during learning of endoscopic surgical skills have been carried out. In the present study, we investigated cortical activation using near-infrared spectroscopy (NIRS) during endoscopic surgical tasks. A total of 21 right-handed subjects, comprising 4 surgical experts, 4 trainees, and 13 novices, participated in the study. Suturing and knot-tying tasks were performed in a box trainer. Cortical activation was assessed in all subjects by task-related changes in hemoglobin (Hb) oxygenation using NIRS. In surgical experts and novices with no experience of endoscopic surgical training, we found no changes in oxy-Hb, deoxy-Hb or total-Hb levels in any of the frontal channels. In surgical trainees and one novice with experience of endoscopic surgical training, we found significant increases in oxy-Hb and total-Hb levels in most of the frontal channels. There were significant differences in oxy-Hb and total-Hb levels in CH-19 between surgical experts and trainees (p = 0.02 for both), and between surgical trainees and novices with no experience of endoscopic surgical training (p = 0.008 for both). Furthermore, additional training increased oxy-Hb levels in the frontal cortex of novices with no experience of endoscopic surgical training but had no such effect on surgical experts. The present data suggest that NIRS is a feasible tool for assessing brain activation during endoscopic surgical tasks, and may have a large impact on the future development of teaching, training, and assessment methods for endoscopic surgical skills.

Hybrid Augmented Reality Simulator: Preliminary Construct Validation of Laparoscopic Smoothness in a Urology Residency Program

We examined the usefulness, reliability and applicability of the smoothness metric of the ProMIS hybrid simulator (Haptica, Dublin, Ireland) for a urology residency program. A total of 15 urology residents divided into junior and senior cohorts were followed prospectively for 6 training sessions. Validated McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) laparoscopic tasks were used. The ProMIS hybrid simulator smoothness parameter, a unit-free metric of movement efficiency, was recorded using 3-dimensional visual tracking technology. Results were compared between cohorts at the midpoint and end of the defined training sessions. End of study junior means were also retrospectively compared to senior mid training means. Statistical significance was determined using the Mann-Whitney U test (alpha = 0.05). Statistically significant differences between 8 junior and 7 senior cohorts were measured in all MISTELS tasks. A statistically significant performance variation was also detected at the mid and end testing times. When juniors and seniors were compared between sessions 1 and 3, and 4 and 6, statistically significant performance improvements were noted. Lastly, statistical differences were also maintained when mid session senior means were compared to end of session junior means. A 38% improvement in task completion in the senior cohort as well as a 10-fold decrease in variance was observed compared to a 12% improvement in juniors, indicating greater efficiency of movement in seniors. The laparoscopic smoothness metric in the hybrid simulator demonstrated construct validity by effectively differentiating between experienced and novice urology residents using validated MISTELS tasks. The outcome suggests that the hybrid simulator smoothness metric is a valuable asset in residency programs for preparatory training for live operative experience, allowing improved trainee assessment.

Could Variations in Technical Skills Acquisition in Surgery Be Explained by Differences in Cortical Plasticity?

SUMMARY/BACKGROUND: Variations in technical performance in surgery are known to exist but are poorly understood. Gaining an appreciation of these differences may have implications for technical skills training, assessment, and selection. Investigators attempting to correlate technical skill with visuospatial or perceptual tests have failed to identify surrogate markers of surgical aptitude. Evidence from unrelated fields suggests that studying brain function may advance our understanding of disparate technical performance in surgery. A literature search was conducted to identify relevant studies assessing both motor skills learning and changes in brain function. The brain is dynamic and patterns of activation vary with experience and training, a property referred to as "neuroplasticity." Functional neuroimaging studies of complex nonsurgical skills have demonstrated smaller, more refined neuronal networks in experts compared with novices. Novel unrefined performance places a significant burden on generic areas of attention and control such as the anterior cingulate cortex and the prefrontal cortex (PFC). These regions are recruited less as skills are performed with increasing automaticity. Persistent PFC activation has been shown to herald poor bimanual coordination learning in studies involving nonsurgical tasks. It is suspected that alterations in brain activation foci accompany a transition through phases of surgical skills learning and that those patterns of activation may vary according to technical ability. Validating this hypothesis is challenging because it requires studying brain function in ambulant subjects performing complex motor skills. In a surgical knot-tying study involving over 60 subjects of varying expertise, PFC activation was identified in novices but not in trained surgeons. Further work should aim to determine whether PFC activation attenuates in the context of learning success in surgery.

The Effect of Computer Navigation on Trainee Learning of Surgical Skills

While computer-assisted orthopaedic surgery technology may facilitate performance and learning in the expert, its effects on the trainee are unclear. Motor learning theory suggests that, while the real-time feedback provided by computer-assisted orthopaedic surgery should improve performance, it may be detrimental to learning. The purpose of this study was to assess the effects of computer-assisted orthopaedic surgery on the learning of surgical skills by trainees. Forty-five participants were randomized to one of three training groups-conventional training, computer navigation, or knowledge of results-in which they learned technical skills related to total hip replacement. Outcomes were assessed in a pretest session and in ten-minute and six-week retention and transfer tests. All groups demonstrated improved accuracy and precision in the determination of the abduction angle and the version angle of the acetabular cups during training (p < 0.001). The computer navigation group demonstrated significantly better accuracy and precision in early training (p < 0.05) and better precision throughout training (p < 0.05). No significant degradation in performance was observed between the immediate and the delayed testing for any group, suggesting that there was task learning in all groups with no negative effects of the tested training modalities on learning. In this study, the concurrent augmented feedback provided by computer-assisted orthopaedic surgery resulted in improved early performance and equivalent learning. While we did not observe a compromise in learning, further investigation is required to ensure that computer-assisted orthopaedic surgery does not compromise trainee learning in more complex tasks.

How much feedback is necessary for learning to suture?

Many laparoscopic simulation training systems exist and have been shown to transfer learning of surgical skills to the operating room. The manner in which the training is structured to maximize learning has not been examined. There are many aspects to the acquisition of laparoscopic skills during training, one of which is the availability of knowledge of results (KR). Knowledge of results is information about the outcome of motor skill execution, usually provided to individuals at the end of the execution. The timing and nature of KR can affect how well people learn new motor skills. In addition, detailed instruction during learning can also affect skill acquisition. We studied the effects of KR and instruction on the learning curve of a suturing and knot-tying task. We hypothesized that KR was necessary for skill acquisition, and that detailed instruction would help trainees to learn to perform the task more correctly and reach a performance plateau earlier. In addition, the overall workload of a trainee during training would decrease as skills improved, especially when KR and coaching were provided. Nine medical students with no previous laparoscopic surgical experience were randomly and evenly divided into three groups with different KR conditions: (1) no KR, (2) KR, (3) KR + instruction. Each subject attended a training session for 1 h each day, 6 days a week for 4 consecutive weeks. Performance measures such as task time, smoothness of instrument, and path length were recorded for each trial. Workload was assessed using the NASA-TLX questionnaire. While KR was necessary for learning to suture, continual instruction had limited additional benefits. However, KR + instruction did reduce subjects' perceived overall workload. Surgical training could be carried out effectively with only knowledge of results. These results have implications for the staffing of surgical skills laboratories.

The Increasing Significance of How to Learn Motor Skills

The training of surgeons has traditionally been an apprenticeship. In recent times it has become increasingly difficult for trainees to acquire operative skills. The acquisition and refinement of these technical skills by the surgical trainee are central to surgical teaching. Much work has been done looking into the theories of motor skill learning, working on the assumptions that if they are understood then tests may be developed to be used as skill predictors. Two schools of thought exist as to the use of neuropsychological factors in learning fine motor skills but all agree that practice and instructional feedback are essential for the correct acquisition of these essential surgical skills. With the current climate of shortened training and new guidelines its even more important to understand skill acquisition and assist in the learning of new surgical skills.