General Surgery Skills Research Articles

Defining the Canadian rural general surgeon.

A total of 18%-30% of Canadians live in a rural area and are served by 8% of the country's general surgeons. The demographic characteristics of Canada's population and its geography greatly affect the health outcomes and needs of the population living in rural areas, and rural general surgeons hold a unique role in meeting the surgical needs of these communities. Rural general surgery is a distinct area of practice that is not well understood. We aimed to define the Canadian rural general surgeon to inform rural health human resource planning. A scoping review of the literature was undertaken of Ovid, MEDLINE, and Embase using the terms "rural," "general surgery," and "workforce." We limited our review to articles from North America and Australia. The search yielded 425 titles, and 110 articles underwent full-text review. A definition of rural general surgery was not identified in the Canadian literature. Rurality was defined by population cut-offs or combining community size and proximity to larger centres. The literature highlighted the unique challenges and broad scope of rural general surgical practice. Rural general surgeons in Canada can be defined as specialists who work in a small community with limited metropolitan influence. They apply core general surgery skills and skills from other specialties to serve the unique needs of their community. Surgical training programs and health systems planning must recognize and support the unique skill set required of rural general surgeons and the critical role they play in the health and sustainability of rural communities.

Confronting new challenges: Faculty perceptions of gaps in current laparoscopic curricula in a changing training landscape

BackgroundOpportunities for residents to develop laparoscopic skills have decreased with the rise in robotic operations and the development of complex, subspecialized laparoscopic operations. Given the changing training landscape, this study aimed to identify laparoscopic surgeons' perceptions of gaps in current laparoscopic skills in general surgery, obstetrics-gynecology, and urology residency programs. MethodsLaparoscopic surgeons who operate with residents participated in semi-structured interviews. Questions addressed expectations for resident proficiency, deficits in laparoscopic surgical skills, and barriers to learning and teaching. Two authors independently coded de-identified transcripts followed by a conventional content analysis. ResultsFourteen faculty members from thirteen subspecialties participated. Faculty identified three main areas to improve laparoscopic training across specialties: foundational knowledge, technical skills, and cognitive skills. They also recognized an overarching opportunity to address faculty development. ConclusionsThis qualitative study highlighted key deficiencies in laparoscopic training that have emerged in the current, changing era of minimally invasive surgery. Key messageThis qualitative study identified laparoscopic educators' perceptions of deficiencies in laparoscopic training. Findings emphasized the importance of incorporating high quality educational practices to optimize training in the current changing landscape of laparoscopic surgery.

448 Foundation Doctor Local Peer-Led and Organised Basic Surgical Skills in General Surgery and Plastic Surgery

Abstract Aim Foundation doctors are under pressure early in their careers to attend highly subscribed and expensive surgical courses. We assessed the feasibility of a foundation doctor led and locally organised basic surgical skills introduction. Method The lead foundation doctor organised a basic surgical skills introduction for foundation year doctors at Salisbury District Hospital liaising with the postgraduate centre and local surgical consultants. This training was supervised by local consultants and registrars. This teaching delivered theory and practise in suturing, knot tying and laparoscopy by local and familiar trainers. Feedback was collected using the Likert scale. Results 12 foundation doctors attended. 100% either agreed or strongly agreed the introduction was helpful and well organised. 25% either agreed or strongly agreed feeling confident with suturing and knot tying before the teaching which increased to 92% after teaching. Only 8.3% either agreed or strongly agreed feeling confident with the principles of basic laparoscopy before teaching which increased to 83% after teaching. 100% either agreed or strongly agreed the teaching will improve their clinical practise and enhance their interest in surgery. 92% strongly agreed or agreed that the teaching improved their knowledge in basic surgical skills, and the peer led and organised structure was an effective teaching method. Conclusions Foundation doctor locally peer led teaching organised with supervision by local consultants is an effective method of delivering basic surgical skills with improvement especially marked in basic laparoscopy and help enhance interest in surgical training.

John Zachariah Laurence: ‘forgotten luminary’

John Zachariah Laurence was one of the four medical staff appointed in 1860 to the new “Hospital for the Paralysed and Epileptic,” at 24 Queen Square, London. A prize-winning graduate of UCH he was known for his high intellect and skills in general surgery and in ophthalmology. After a brief period at Queen Square he left to found the South London Ophthalmic Hospital that became the Royal Eye Hospital, and the “Ophthalmic Review”, the first British journal of ophthalmology; he later served at Barts. Highly accomplished in the arts, literature and research his achievements were sadly neglected by his contemporaries.

Application of virtual-simulation laparoscopic training system in the teaching of general surgery skills

Objective To investigate the effect of virtual-simulation laparoscopic training system in the training of basic skills of endoscopic surgery in trainees with different clinical experience. Method s Eight refresher physicians, eight residents who received standardized residency training, and eight undergraduate interns in five-year clinical medicine were selected. All of them received the training of endoscopic operations with the laparoscopic training box and the virtual-simulation laparoscopic training system for 30 minutes every day for 4 weeks. Data analyses were performed using SPSS 19.0 and t-test was adopted to compare the scores before and after training among the three groups. Result s Before training, there were significant differences in endoscopic operations between the undergraduate intern group and the other two groups (P 0.05), and the undergraduate intern group had a significantly higher score of complex operations than did the standardized residency training group and the refresher physician group (P<0.05). Conclusion The virtual-simulation laparoscopic training system can improve the laparoscopic skills of clinical trainees at different levels, therefore, it is worth being promoted in the teaching of clinical skills. Key words: Virtual-simulation training system; Laparoscopy; Simulation teaching; Application

Self-Assessment of Surgical Skills: A Systematic Review

Self-assessment is fundamental in surgical training to enhance learning in the absence of trainer feedback. The primary objective of this review was to assess the factors that influence accuracy of self-assessment at technical skills across all surgical specialties. The secondary objective was to assess whether there are any innate factors or attributes to predict those that will carry out effective self-assessment. A systematic review was carried out in accordance with PRISMA guidelines. A search strategy encompassing MEDLINE, EMBASE, ERIC, WHO, and the Cochrane database was conducted to identify studies investigating self-assessment at any surgical task. Quality was assessed using the Newcastle-Ottawa scale. A summary table was created to describe specialty, participants, task, setting, assessment tool, and correlation coefficient between self and expert assessment. The review protocol was registered in PROSPERO. Of 24,638 citations, 40 met inclusion criteria. In total 1753 participants performed 68 procedures. Twenty-six studies investigated skills in general surgery with the remaining 14 in various other surgical specialties. Accuracy of self-assessment is superior in those with greater experience and age, and with use of retrospective video playback. Accuracy tends to be reflected by overestimation of performance. Stressful environments reduce accuracy. There is limited evidence in the literature regarding predicting traits for those who will carry out accurate self-assessment. The ability to perform accurate self-assessment is an important skill in surgical training, with accuracy being influenced by a multitude of factors. The use of self-assessment from retrospective video playback may be of benefit in surgical training curricula to enhance learning of technical skills. Further studies are required to define predictors of good self-assessment, which will strengthen recruitment and mentoring to assist trainee learning.

Are American Surgical Residents Prepared for Humanitarian Deployment?: A Comparative Analysis of Resident and Humanitarian Case Logs

Effective humanitarian surgeons require skills in general surgery, OB/GYN, orthopedics, and urology. With increasing specialization, it is unclear whether US general surgery residents are receiving exposure to these disparate fields. We sought to assess the preparedness of graduating American surgical residents for humanitarian deployment. We retrospectively analyzed cases performed by American College of Graduate Medical Education general surgery graduates from 2009 to 2015 and cases performed at select Médecins Sans Frontières (MSF) facilities from 2008 to 2012. Cases were categorized by specialty (general surgery, orthopedics, OB/GYN, urology) and compared with Chi-squared testing. Non-operative care including basic wound and drain care was excluded from both data sets. US general surgery residents performed 41.3% MSF relevant general surgery cases, 1.9% orthopedic cases, 0.1% OB/GYN cases, and 0.3% urology cases; the remaining 56.4% of cases exceeded the standard MSF scope of care. In comparison, MSF cases were 30.1% general surgery, 21.2% orthopedics, 46.8% OB/GYN, and 1.9% urology. US residents performed fewer OB/GYN cases (p<0.01) and fewer orthopedic cases (p<0.01). Differences in general surgery and urology caseloads were not statistically significant. Key procedures in which residents lacked experience included cesarean sections, hysterectomies, and external bony fixation. Current US surgical training is poorly aligned with typical MSF surgical caseloads, particularly in OB/GYN and orthopedics. New mechanisms for obtaining relevant surgical skills should be developed to better prepare American surgical trainees interested in humanitarian work.

Crowd-sourced assessment of technical skills: an opportunity for improvement in the assessment of laparoscopic surgical skills

BackgroundObjective, unbiased assessment of surgical skills remains a challenge in surgical education. We sought to evaluate the feasibility and reliability of Crowd-Sourced Assessment of Technical Skills. MethodsSeven volunteer general surgery interns were given time for training and then testing, on laparoscopic peg transfer, precision cutting, and intracorporeal knot-tying. Six faculty experts (FEs) and 203 Amazon.com Mechanical Turk crowd workers (CWs) evaluated 21 deidentified video clips using the Global Objective Assessment of Laparoscopic Skills validated rating instrument. ResultsWithin 19 hours and 15 minutes we received 662 eligible ratings from 203 CWs and 126 ratings from 6 FEs over 10 days. FE video ratings were of borderline internal consistency (Krippendorff’s alpha = .55). FE ratings were highly correlated with CW ratings (Pearson’s correlation coefficient = .78, P < .001). ConclusionWe propose the use of Crowd-Sourced Assessment of Technical Skills as a reliable, basic tool to standardize the evaluation of technical skills in general surgery.

Are general surgeons able to accurately self-assess their level of technical skills?

Self-assessment is a way of improving technical capabilities without the need for trainer feedback. It can identify areas for improvement and promote professional medical development. The aim of this review was to identify whether self-assessment is an accurate form of technical skills appraisal in general surgery. The PubMed, MEDLINE(®), Embase(™) and Cochrane databases were searched for studies assessing the reliability of self-assessment of technical skills in general surgery. For each study, we recorded the skills assessed and the evaluation methods used. Common endpoints between studies were compared to provide recommendations based on the levels of evidence. Twelve studies met the inclusion criteria from 22,292 initial papers. There was no level 1 evidence published. All papers compared the correlation between self-appraisal versus an expert score but differed in the technical skills assessment and the evaluation tools used. The accuracy of self-assessment improved with increasing experience (level 2 recommendation), age (level 3 recommendation) and the use of video playback (level 3 recommendation). Accuracy was reduced by stressful learning environments (level 2 recommendation), lack of familiarity with assessment tools (level 3 recommendation) and in advanced surgical procedures (level 3 recommendation). Evidence exists to support the reliability of self-assessment of technical skills in general surgery. Several variables have been shown to affect the accuracy of self-assessment of technical skills. Future work should focus on evaluating the reliability of self-assessment during live operating procedures.

Defining our destiny: trainee working group consensus statement on the future of emergency surgery training in the United Kingdom.

The United Kingdom National Health Service treats both elective and emergency patients and seeks to provide high quality care, free at the point of delivery. Equal numbers of emergency and elective general surgical procedures are performed, yet surgical training prioritisation and organisation of NHS institutions is predicated upon elective care. The increasing ratio of emergency general surgery consultant posts compared to traditional sub-specialities has yet to be addressed. How should the capability gap be bridged to equip motivated, skilled surgeons of the future to deliver a high standard of emergency surgical care? The aim was to address both training requirements for the acquisition of necessary emergency general surgery skills, and the formation of job plans for trainee and consultant posts to meet the current and future requirements of the NHS.Twenty nine trainees and a consultant emergency general surgeon convened as a Working Group at The Association of Surgeons in Training Conference, 2015, to generate a united consensus statement to the training requirement and delivery of emergency general surgery provision by future general surgeons. Unscheduled general surgical care provision, emergency general surgery, trauma competence, training to meet NHS requirements, consultant job planning and future training challenges arose as key themes. Recommendations have been made from these themes in light of published evidence. Careful workforce planning, education, training and fellowship opportunities will provide well-trained enthusiastic individuals to meet public and societal need.

Specialist registrar skills in general surgery

The specialist registrar skills in general surgery course is a four day programme run centrally by the Royal College of Surgeons of England that can be completed at a number of hospitals nationwide. Currently, dates are available in Liverpool (where I did the course) and Cardiff. The course gives a grounding in bowel anastomosis, vascular anastomosis, and the core principles of laparoscopic surgery. Officially the course is aimed at trainees in general surgery, from core training year 1 (CT1) to specialty training year 4 (ST4). At the session I attended candidates were mostly from ST3, with a few in CT2 and non-training registrar posts. To get the most out of the course I would recommend that core trainees wait until they are well into CT2. Those who have worked as registrars for more than …

Sichuan Earthquake and Emergency Relief Care for Children

An 8.0-magnitude earthquake struck Sichuan province of China on May 12, 2008. Over the next 10 days, the firstly arrived uniformed pediatricians in the epicenter zone took part in emergency relief care for children. The investigations of major injuries and diseases in children were taken. Demographic data collected included (if possible) age, date of presentation, injury, disease, and surgery performed. Total casualties were estimated to be more than 80,000, and much more were injured. Eight hundred eighty-two inpatients were treated by the relief team during the first 10 days. Of 882 inpatients, 192 (21.8%) were younger than 18 years. Children's ages were not evenly distributed. Twenty-seven patients were neonates, infants, and toddlers (14%), 105 were school-aged (55%), and were 60 adolescents (31%). The admitted children had 256 injuries. Limb (106 cases, 55.2%) and body surface (67 cases, 34.9%) were the majorly injured locations. One hundred twenty-seven cases (66.2%) had simple open injuries, and 106 (55.2% had fractures. The children's conditions were evaluated as mild (121 cases, 63.0%), moderate (56 cases, 29.7%), severe (8 cases, 4.2%), and fatal (7 cases, 3.7%). More than 20% of patients requiring hospitalization were children. School-aged children were heavily injured. The increase in infectious diseases followed on. The data show that there is an immediate need for orthopedic and general surgery skills, and pediatricians should play an important role in early rescue and subsequent control of infectious diseases in a huge earthquake hazard.

Addressing gaps in surgical skills training by means of low-cost simulation at Muhimbili University in Tanzania.

BackgroundProviding basic surgical and emergency care in rural settings is essential, particularly in Tanzania, where the mortality burden addressable by emergency and surgical interventions has been estimated at 40%. However, the shortages of teaching faculty and insufficient learning resources have hampered the traditionally intensive surgical training apprenticeships. The Muhimbili University of Health and Allied Sciences consequently has experienced suboptimal preparation for graduates practising surgery in the field and a drop in medical graduates willing to become surgeons. To address the decline in circumstances, the first step was to enhance technical skills in general surgery and emergency procedures for senior medical students by designing and implementing a surgical skills practicum using locally developed simulation models.MethodsA two-day training course in nine different emergency procedures and surgical skills based on the Canadian Network for International Surgery curriculum was developed. Simulation models for the surgical skills were created with locally available materials. The curriculum was pilot-tested with a cohort of 60 senior medical students who had completed their surgery rotation at Muhimbili University. Two measures were used to evaluate surgical skill performance: Objective Structured Clinical Examinations and surveys of self-perceived performance administered pre- and post-training.ResultsThirty-six students participated in the study. Prior to the training, no student was able to correctly perform a surgical hand tie, only one student was able to correctly perform adult intubation and three students were able to correctly scrub, gown and glove. Performance improved after training, demonstrated by Objective Structured Clinical Examination scores that rose from 6/30 to 15/30. Students perceived great benefit from practical skills training. The cost of the training using low-tech simulation was four United States dollars per student.ConclusionSimulation is valued to gain experience in practising surgical skills prior to working with patients. In the context of resource-limited settings, an additional benefit is that of learning skills not otherwise obtainable. Further testing of this approach will determine its applicability to other resource-limited settings seeking to develop skill-based surgical and emergency procedure apprenticeships. Additionally, skill sustainability and readiness for actual surgical and emergency experiences need to be assessed.

Applying skills in general surgery: Preparing medical students for careers in surgery

Introduction. Applying Skills in General Surgery is an elective course designed to encourage student interest in general surgery and to prepare students for surgical residency through daily didactic sessions, daily cadaveric simulations of common surgical procedures, and a porcine laparoscopic cholecystectomy. Methods. Fifteen third- and fourth-year medical students enrolled in the elective were given pre- and postcourse surveys with Likert scale questions evaluating perceptions of preparedness for residency and medical specialty choice. Survey results were compared using paired Student’s t-test where P < 0.05 is significant. Results. Thirteen students had chosen a career in general surgery or a surgical subspecialty (Orthopedics, ENT, Urology); one was undecided, and one had chosen anesthesiology. Students who had chosen a specialty prior to the course were, on average, greater than “somewhat sure” of their career choice (AVG 4.38, SD 0.82) and postcourse surveys demonstrated no change in specialty choice. However, the top two reasons students enrolled in the course were to improve technical skills (>90%) and to prepare for residency (40%). Subjective data evaluating preparedness for residency are presented in the table. TABLE—ABSTRACT 64 Pre-course Post-course P-val AVG SD AVG SD I understand the: Underlying anatomy 3.47 0.92 4.67 0.62 0.002 Role of radiology 3.60 0.83 3.80 0.86 0.424 Diagnostic algorithm 3.07 1.16 4.13 0.74 0.008 Treatment algorithm 2.80 1.01 4.07 0.70 0.004 I am comfortable with my: Suturing skill level 3.00 0.93 4.33 0.62 0.001 Conclusions. Although the Applying Skills in General Surgery course does not appear to influence medical students’ choice of specialty, this innovative educational model is excellent preparation for surgical residency based upon reported improvement in medical students’ surgical skills and fund of knowledge regarding underlying surgical anatomy and algorithms of surgical diagnosis and treatment.

Pediatric surgical emergencies in the setting of a natural disaster: Experiences from the 2001 earthquake in Gujarat, India

Background/Purpose: On January 26, 2001, a 7.9 Richter earthquake struck the Indian state of Gujarat. Over the next 6 days, the International Red Cross set up a mobile hospital in the city of Bhuj, near the epicenter. The authors describe all surgeries on children treated there during the first 4 weeks of operation. The evolution of presenting injuries is noted, the types of surgery required are classified and an effective disaster relief team composition and strategy are proposed. Methods: Total casualties were estimated at 30,000, with 250,000 people injured. Of 1,142 inpatients treated at Nor-Finn hospital during the first 4 weeks, approximately 300 (25%) were ≤17 years old. Of these, the authors report on the 62 who underwent surgery. Demographic data collected includes (where possible) age, date of presentation, injury, and surgery performed. Injuries are classified as orthopedic, soft tissue, burns, or miscellaneous. Injuries are grouped in 4 weekly time periods beginning February 1 when the hospital opened. Results: Children's ages were evenly distributed. Children required surgery less often than adults. Of children needing surgery, 42% needed orthopedic attention, 42% had soft tissue trauma, 10% had burns, and 6% had miscellaneous injuries. During the hospital's first week, operations were predominantly orthopedic. During the second week, orthopedic and soft tissue injuries occurred at similar frequency. In weeks 3 and 4, soft tissue and burn surgeries were prevalent. Conclusions: More than 25% of patients requiring hospitalization were children, of whom greater than 20% needed surgery. The operations fell into 4 categories: orthopedic, soft tissue injuries, burns, and miscellaneous. There was an immediate need for orthopedic and general surgery skills followed by a delayed need for plastic surgery skills. J Pediatr Surg 38:663-667. © 2003 Elsevier Inc. All rights reserved.