Stepwise Training Program Research Articles

Robotic colorectal surgery training: Portsmouth perspective.

This study aims to discuss the principles and pillars of robotic colorectal surgery training and share the training pathway at Portsmouth Hospitals University NHS Trust. A narrative review is presented to discuss all the relevant and critical steps in robotic surgical training. Robotic training requires a stepwise approach, including theoretical knowledge, case observation, simulation, dry lab, wet lab, tutored programs, proctoring (in person or telementoring), procedure-specific training, and follow-up. Portsmouth Colorectal has an established robotic training model with a safe stepwise approach that has been demonstrated through perioperative and oncological results. Robotic surgery training should enable a trainee to use the robotic platform safely and effectively, minimize errors, and enhance performance with improved outcomes. Portsmouth Colorectal has provided such a stepwise training program since 2015 and continues to promote and augment safe robotic training in its field. Safe and efficient training programs are essential to upholding the optimal standard of care.

Stepwise training program: A novel practice schedule for laparoscopic suturing

PurposeWe establish stepwise training program in which laparoscopic suturing is broken down to discrete steps. The purpose is to evaluate the learning outcomes of stepwise training program. Materials and methodsVolunteer participants were enrolled from medical students and surgical trainees. Students took two courses of 2-h stepwise training, and a post-course (1st & 2nd) test was taken after each course; trainees took one course of stepwise training with a pre-course (1st) and a post-course (2nd) test. Attending surgeons took the test as control. Learning outcomes were assessed with laparoscopic suturing competency assessment tool (LS-CAT) and suturing time. ResultsThere were 10 students, 8 trainees and 6 surgeon controls. Suturing time and LS-CAT scores significantly improved between the 1st and 2nd test (p < 0.01). In the both tests, suturing time and LS-CAT scores of students and trainees were similar. In the 1st test, surgeons had significantly better performance in suturing time and LS-CAT score than students and trainees; in the 2nd test, the LS-CAT scores of students and trainees were similar to the surgeon controls. ConclusionsStepwise program effectively enhances laparoscopic suturing skill for medical students and surgical trainees. Catch-up effect was demonstrated in medical students with stepwise training.

Simulation training of laparoscopic pancreaticojejunostomy and stepwise training program on a 3D-printed model

AimLaparoscopic pancreaticojejunostomy is among the most difficult and high-risk operations. Surgeons with low or moderate seniority rarely are allowed to perform this surgery in clinics. Therefore, there is an urgent need to develop a reliable simulation training model focused on laparoscopic pancreaticojejunostomy and an effective stepwise training program. MethodsSurgeons with different working experiences or exposure to different training programs at Sir Run Run Shaw Hospital were divided into four groups. Each was required to perform laparoscopic pancreaticojejunostomy using a designed three-dimensional dry lab model. All surgeons' baseline characteristics and surgical performance, including operation time and score, were recorded and analysed. The authenticity of the model was evaluated by four senior surgeons. ResultsThe surgeon group with higher seniority had an older average age, longer working time, and had completed more laparoscopic cholecystectomy and laparoscopic common bile duct exploration procedures. Meanwhile, the surgeon group with higher seniority presented better operation performance, including shorter operation time and higher operation score in their initial simulation training. Resident surgeons who underwent stepwise training with the laparoscopic biliary-enteric anastomosis training program showed better initial performance than resident surgeons who underwent stepwise training with the laparoscopic basic suture training program. After repeated training, the surgeons showed improved surgical performance. ConclusionOur pancreaticojejunostomy model showed a good degree of discernibility, as surgeons with more experience performed better with the model for their initial simulation training in laparoscopic pancreaticojejunostomy. Stepwise training of the laparoscopic biliary-enteric anastomosis training program helped surgeons obtain a better initial performance, and repeated simulation training on this model improved the surgeon's operative performance.

V-023 R-TAPP AS A TRAINING MODEL IN ROBOTIC SURGERY

Abstract Aim The main aim of the project will be evaluating the effectiveness of an experimental structured didactic program in robotic surgery in filling the training gap caused by the pandemic. We intend to evaluate how establishing a training pathway could improve young surgeons’ robotic skills and implement their participation in robotic procedures during the COVID-19 pandemic. We will also evaluate the learning curve of robotic transabdominal preperitoneal inguinal hernia repair (TAPP) for young surgeons with limited experience as first operators at the dual console. Matherials and Methods We designed an experimental stepwise training program in robotic surgery that starts from a first step of theoretical and laboratory lessons, followed by a second phase of bedside assistance training, and finally the completion of low complexity procedures by the trainees proctored at the dual console by senior surgeons. Robotic TAPP was selected as training model. The performance of each trainee will be registered in an evaluation data sheet and Learning scores will be recorded by the tutor with the evaluation of 6 corner steps of the procedure. Results Preliminary results showed improved technical skills and increased team spirit and wellbeing. Conclusions TAPP is a good training model because involves technical steps useful for more complex procedures. The robotic dual console represent an extraordinary training tool and a structured training program positively impacts technical skills and could help filling the training gap caused by the pandemic.

Can training on ex-vivo models increase neurointerventionalists' subjective self-confidence in the operating room?

In a changing learning environment where young neurointerventionalists spend less time in the operating room, computer simulators have been established as a new training model. Our aim was the comparison of silicone models and computer simulators, and the evaluation of their influence on subjective self-confidence of operators. Pre- and postquestionnaires of 27 participants and 9 tutors were evaluated after the participation in a three-days interventional stroke course using silicone models and computer simulators. Training on computer simulators was considered as more realistic and important before patient contact than training on silicone models. Participants rated their own abilities as significantly better after participation in the course and felt significantly better prepared for patient care. Training on computer simulators can increase the subjective self-confidence of trainees. We suggest a stepwise training program, comprising both ex-vivo and the porcine in-vivo model, finished by conventional operating room teaching, to prepare neuroradiologists for optimal patient care when performing interventions.

Usefulness of a stepwise training program for laparoscopic gastrectomy.

Laparoscopic gastrectomy (LG) is a complicated procedure with a long learning curve. This study was performed to investigate the usefulness of our stepwise training program for LG for improving the quality of the surgery. The stepwise training method comprised the following four steps: (1) basic training using a dry box and checking by mentors; (2) advanced training, including the use of animals and cadavers; (3) clinical experience, including standardization and preoperative three-dimensional simulation; and (4) self-assessment and feedback. In total, 153 patients who underwent curative gastrectomy for gastric cancer were included in this study. The operative time gradually decreased for both laparoscopic distal gastrectomy (LDG) (2013, 395 minutes; 2017, 278 minutes; P < .001; ρ=-0.68) and laparoscopic total gastrectomy (LTG) (2013, 476 minutes; 2017, 319 minutes; P < .001; ρ=-0.56). The blood loss volume gradually decreased for both LDG (2013, 43.0mL; 2017, 18.6mL; P < .005; ρ=-0.30) and LTG (2013, 143.8mL; 2017, 13.5mL; P < .005; ρ=-0.41). Our stepwise training program contributes to reduce operation time and blood loss in LG.

Comparison of Hemorrhagic Complications with Double-ligated versus Auto-ligated Feline Ovarian Pedicles by Fourth-Year Veterinary Students.

The objective of this article is to compare the occurrence of hemorrhagic complications in student-performed feline ovarian pedicle ligations using the traditional suture pedicle double-ligation (PDL) to the suture-less auto-ligation (AL) techniques, and to describe the stepwise method of teaching the AL technique to students. A total of 287 cats underwent an ovariohysterectomy (OHE) performed by a fourth-year veterinary student trained by veterinary faculty to perform the AL technique beginning with a low-fidelity model and progressing to live patient surgeries. Students performed the AL and PDL techniques on 146 and 141 cats respectively. Hemorrhagic complications occurred in 4 of 146 cats (2.7%) in the AL group and 8 of 141 (5.7%) in the PDL group and were not found to be significantly different (p = 0.2496). This article demonstrates that novice surgeons can safely perform the AL technique on feline ovarian pedicles without significantly increasing complications compared to the traditionally taught method when a stepwise training program is implemented. Additionally, this technique has been shown to be safe, effective, and more efficient when performed by experienced veterinary surgeons.1 Veterinary institutions should consider including the AL technique in their core curricula as a standard method for feline ovarian pedicle ligation. Doing so will facilitate the development of more proficient entry-level practitioners who are better able to serve their patients, clients, employers, humane societies, and their communities by using a more efficient and safe feline ovariohysterectomy technique.

The Usefulness of a Preoperative Nomogram for Predicting the Probability of Conversion from Laparoscopic to Open Distal Pancreatectomy: A Single-Center Experience

BackgroundLaparoscopic distal pancreatectomy (LDP) represents a challenging procedure with a high conversion rate. A nomogram is a simple statistical predictive tool which is superior to risk groups. The aim of this study was to develop and validate a preoperative nomogram for predicting the probability of conversion from laparoscopic to open distal pancreatectomy.MethodsThis is a retrospective study of 100 consecutive patients who underwent LDP. For each patient demographic, pre-intra- and postoperative data were collected. Univariate and multivariate analyses were carried out to identify the factors significantly influencing the conversion rate. The effect of each factor was weighted using the beta coefficient (β), and a nomogram was built. Finally, a logistic regression between the score and the conversion rate was carried out to calibrate the nomogram.ResultsThe conversion rate was 19.0%. At multivariate analysis, female (β = − 1.8 ± 0.9; P = 0.047) and tail location of the tumor (β = − 2.1 ± 1.1; P = 0.050) were significantly related to a low probability of conversion. Body mass index (BMI) (β = 0.2 ± 0.1; P = 0.011) and subtotal pancreatectomy (β = 2.4 ± 0.9; P = 0.006) were factors independently related to a high probability of conversion. The nomogram constructed had a minimum value of 4 and a maximum value of 18 points. The probability of conversion increased significantly starting from a minimum score of 6 points (P = 0.029; conversion probability 14.4%; 95%CI, 1.5–27.3%) up to 16 (P = 0.048; 27.8%; 95%CI, 0.2–48.7%).ConclusionThe nomogram proposed could serve as an effective preoperative tool capable of assessing the probability of conversion, allowing to take reliable decisions regarding indications and adequate stepwise training program of LDP.

The Influence of Surgical Experience on Postoperative Recovery in Fast-Track Bariatric Surgery.

Short duration of surgery is an important aspect in fast-track protocols. Peroperative training of surgical residents could influence the duration of surgery, possibly affecting patient outcome. This study evaluates the influence of the operator's level of experience on patient outcome in fast-track bariatric surgery. Data was analyzed of all patients who underwent a primary laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) between January 2004 and July 2018. Residents were trained according to a stepwise training program. For each operator, learning curves of both procedures were created by dividing the procedures in time-subsequent groups (TSGs). Data was also analyzed by comparing "beginners" with "experienced operators," with a cut-off point at 100 procedures. Primary outcome measure was duration of surgery. Secondary outcome measures were length of hospital stay (LOS), complications, and readmission rate within 30days postoperatively. There were 4901 primary procedures (53.1% LSG) performed by seven surgeons or surgical residents. We found no difference between beginning and experienced operators in complications or readmissions rates. The experience of the operator did not influence LOS (p = 0.201). Comparing each new operator with previous operator(s), the starting point in terms of duration of surgery was shorter, and the learning curve was steeper. The duration of surgery was significantly longer for supervised beginning operators as compared with experienced operators. Within the stepwise training program for residents, there is a slight increase in duration of surgery in the beginning of the learning curve, without affecting the patient outcome.

A Stepwise Approach in Learning Surgical Residents a Roux-en-Y Gastric Bypass.

This study describes a stepwise training program to teach a laparoscopic Roux-en-Y gastric bypass (LRYGB). Results of a resident are compared to experienced bariatric surgeons (EBS). The resident performed a varying amount of surgical steps and the duration of every step was measured using video analysis. In order to compare the resident's results to EBS, the average time per step was calculated for 30 procedures. The total procedure time of LRYGB was 61.15 (± 8.74)min for a novice resident. In comparison, the average of three EBS was 36.22 (± 9.06)min. Creation of the gastric pouch had an average of 12.82 (± 4.08) versus 6.93 (± 2.58)min. Duration of creating the stapled gastrojejunostomy was 7.43 (± 2.11) versus 4.48 (± 2.02)min. Suturing of the gastrojejunostomy was 12.60 (± 3.31) compared to 6.31 (± 2.53)min. Creating the jejunojejunal anastomosis had a duration of 7.12 ( ±2.31) versus 4.22 (± 1.60)min and suturing this anastomosis was 13.93 (± 3.81) compared to 8.51 (± 3.37)min. At the end of the traineeship, the observed progression approximated the skills level of the EBS. The stepwise LRYGB-training program, analysed in this study, can result in an efficient and safe way to approach the learning curve to the level of the EBS. Within this training program, the total time of the operation is kept low in order to prevent adverse events for the patient and loss of efficiency in the bariatric program. The results of this study could act as a guideline for the development of such training programs.

Eliminating Learning Curve–Related Morbidity in Fast Track Laparoscopic Roux-en-Y Gastric Bypass

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is associated with a significant learning curve. We report the results of a systematic training program from a high-volume bariatric center measuring the outcome by comparing the results with data from a consecutive series of 1000 fast-track LRYGB. Using a stepwise training program, the Roux-en-Y gastric bypass operation was divided into an upper and lower procedure and subdivided into 11 well-defined steps. A laparoscopic surgeon without experience in upper-gastrointestinal surgery was mentored by an experienced bariatric surgeon. During 6-month full-time fellowship, 300 operations were performed. The trainee surgeon performed 61 upper procedures and 121 lower procedures in which the mentor surgeon did the other part of the operation. In 110 patients, the trainee performed both procedures. Two percent had perioperative complications compared with 1% of 1000 patients. All were repaired and had an uneventful recovery. Two percent had postoperative complications <30 days compared with 2.8% in the clinic. In the trainees series, there were no leaks compared with 1% in 1000 patients. Operative time was 56/55/70 minutes for operation 0-100/100-200/200-300 compared with an average of 47 minutes registered in the clinic. Concerning time to discharge, there was no difference between patients operated by the trainee and the standard of the clinic. Using a systematic training program in LRYGB surgery eliminates morbidity of the learning curve without affecting the volume.

Training Surgeons to Perform Robotically Assisted Totally Endoscopic Coronary Surgery

Robotic totally endoscopic coronary bypass (TECAB) surgery was developed during the past decade, and younger surgeons need to be trained in this new modality. This study assessed the learning curves and independent TECAB performance of 2 junior surgeons undergoing TECAB training. Two surgeons in training performed portions of 44 of 239 robotic TECAB operations, including left (LIMA) and right interior mammary artery (RIMA) harvesting, lipectomy, pericardiotomy, and IMA to left anterior descending coronary artery (LAD) anastomotic suturing. The procedure portions performed faster by the senior surgeon vs trainees were, in minutes (range), lipectomy, 5 (2 to 18) vs 10 (5 to 21; p < 0.001); pericardiotomy, 5 (1 to 21) vs 7 (3 to 16; p = 0.001); RIMA takedown, 35 (25 to 48) vs 49 (40 to 55; p = 0.034); and LIMA to LAD anastomosis, 26 (12 to 100) vs 34 (24 to 67; p = 0.043). After assuming senior roles in the robotic cardiac surgery program, the 2 trained surgeons performed 14 TECABs (LIMA to LAD) without the senior surgeon. Lipectomy took 5 (3 to 8) minutes; pericardiotomy, 5 (2 to 10) minutes; LIMA takedown, 43 (27 to 70) minutes; LIMA to LAD anastomosis, 24 (15 to 60) minutes, cardiopulmonary bypass time, 73 (40 to 126) minutes; and aortic endo-occlusion time, 53 (0 to 83) minutes. No hospital deaths occurred. TECAB can be well taught with a stepwise training program involving portions of the procedure performed by trainees. With such an approach, independent performance after training can be within adequate time limits and yields seemingly acceptable results.

Qualities and Health of Lay Trainers With Migraine for Behavioral Attack Prevention

To evaluate the qualities of lay trainers with migraine and to quantify their self-management results. Little is known about the qualities of lay trainers with chronic diseases and the benefits for their own health. Thirteen lay trainers (12 F, 1 M) completed a 3-step program that consisted of self-experience of a behavioral training (BT), providing BT to one fellow patient, and subsequently to a small group at home. Successful mastery of own migraine attacks was required for participation, and lay trainers received intensive guidance. Evaluation of the qualities of trainers took place post-BT by means of a specially constructed questionnaire. Their self-management was measured before self-experience of BT, post-BT, and at 6-month follow-up by a headache diary and questionnaires. The qualities of the 13 trainers were positively evaluated by 95 trainees, particularly their warmth, expertise, organization, explanation of BT, active control, and advice and guidance. Higher active control of lay trainers during the group sessions was significantly related to improvements on migraine frequency and internal locus of control in their trainees post-BT. Advice and guidance increased the likelihood of less attacks at follow-up and supportive encouragement promoted a higher internal locus of control. However, humor slightly increased the likelihood of more attacks post-BT, while fellowship and individualization negatively influenced internal locus of control. Lay trainers showed significantly more improvement in migraine frequency than their trainees at follow-up, as well as enhanced internal locus of control and quality of life. Participation in a stepwise training program can produce capable trainers and may positively influence their own health. Lay trainers may be more motivated to enhance their self-management skills as they have to present the benefits to their trainees.

The preliminary effectiveness of migraine lay trainers in a home-based behavioural management training

Objectives This pilot study examined the effectiveness and trainer skills of the first migraine lay trainers (MLTs). Methods In a stepwise training program eight MLTs participated in a behavioural management training (BMT) aimed at the prevention of migraine attacks by proactive relaxation and trigger management. After successful reduction of their migraine attacks, three MLTs provided BMT under supervision at home to one fellow patient and subsequently to a small group. Results Migraine frequency was significantly reduced in five out of eight patients trained by MLTs (mean 48%) and medication use decreased substantially in four patients (mean 47%). Qualities of MLTs concerned their motivational assistance, knowledge of premonitory symptoms and exchange of disease specific problems. Pitfalls were that migraine symptoms hampered an active guidance of the sessions and providing tailored feedback was difficult. Conclusion The first MLTs were successful in training fellow patients in behavioural prevention of migraine attacks. Practice implications Continuous supervision of MLTs health and trainer skills is recommended but is likely to have implications for cost-effectiveness.