Training to proficiency in surgery using simulation: is there a moral obligation?

A deontological approach to surgical ethics advocates that patients have the right to receive the best care that can be provided. The ‘learning curve’ in surgical skill is an observable and measurable phenomenon. Surgical training may therefore carry risk to patients. This can occur directly, through inadvertent harm, or indirectly through theatre inefficiency and associated costs. Trainee surgeon operating, however, is necessary from a utilitarian perspective, with potential risk balanced by the greater societal need to train future independent surgeons.New technology means that the surgical learning curve could take place, at least in part, outside of the operating theatre. Simulation-based deliberate practice could be used to obtain a predetermined level of proficiency in a safe environment, followed by simulation-based assessment of operative competence. Such an approach would require an overhaul of the current training paradigm and significant investment in simulator technology. This may increasingly be viewed as necessary in light of well-discussed pressures on surgical trainees and trainers.This article discusses the obligations to trainees, trainers and training bodies raised by simulation technology, and outlines the current arguments both against and in favour of a simulation-based training-to-proficiency model in surgery. The significant changes to the current training paradigm that would be required to implement such a model are also discussed.

Movement-level process modeling of microsurgical bimanual and unimanual tasks

Purpose Microsurgical techniques require highly skilled manual handling of specialized surgical instruments. Surgical process models are central for objective evaluation of these skills, enabling data-driven solutions that can improve intraoperative efficiency. Method We built a surgical process model, defined at movement level in terms of elementary surgical actions ($$n=4$$ n = 4 ) and targets ($$n=4$$ n = 4 ). The model also included nonproductive movements, which enabled us to evaluate suturing efficiency and bi-manual dexterity. The elementary activities were used to investigate differences between novice ($$n=5$$ n = 5 ) and expert surgeons ($$n=5$$ n = 5 ) by comparing the cosine similarity of vector representations of a microsurgical suturing training task and its different segments. Results Based on our model, the experts were significantly more efficient than the novices at using their tools individually and simultaneously. At suture level, the experts were significantly more efficient at using their left hand tool, but the differences were not significant for the right hand tool. At the level of individual suture segments, the experts had on average 21.0 % higher suturing efficiency and 48.2 % higher bi-manual efficiency, and the results varied between segments. Similarity of the manual actions showed that expert and novice surgeons could be distinguished by their movement patterns. Conclusions The surgical process model allowed us to identify differences between novices’ and experts’ movements and to evaluate their uni- and bi-manual tool use efficiency. Analyzing surgical tasks in this manner could be used to evaluate surgical skill and help surgical trainees detect problems in their performance computationally.

An Evaluation of YouTube Videos as a Surgical Instructional Tool for Endoscopic Endonasal Approaches in Otolaryngology

Objectives Online surgical videos are an increasingly popular resource for surgical trainees, especially in the context of the COVID-19 pandemic. Our objective was to assess the instructional quality of the YouTube videos of the transsphenoidal surgical approach (TSA), using LAParoscopic surgery Video Educational Guidelines (LAP-VEGaS). Methods YouTube TSA videos were searched using 5 keywords. Video characteristics were recorded. Two fellowship-trained rhinologists evaluated videos using LAP-VEGaS (scale 0 [worst] to 18 [best]). Results The searches produced 43 unique, unduplicated videos for analysis. Mean video length 7 minutes (standard deviation [SD] = 13), mean viewership was 16 017 views (SD = 29 415), and mean total LAP-VEGaS score was 9 (SD = 3). The LAP-VEGaS criteria with the lowest mean scores were presentation of the positioning of the patient/surgical team (mean = 0.2; SD = 0.6) and the procedure outcomes (mean = 0.4; SD = 0.6). There was substantial interrater agreement (κ = 0.71). Conclusions LAP-VEGaS, initially developed for laparoscopic procedures, is useful for evaluating TSA instructional videos. There is an opportunity to improve the quality of these videos.

P-O05 Deconstructing Operations to Improve Recording of Surgical Training Experience

Background A new outcomes-based curriculum is soon to be implemented for UK surgical trainees. Performance will be evaluated against the standard expected of a new consultant. Accurate recording of operative experience and performance will therefore be crucial to demonstrate achievement of this standard. The current eLogbook system for recording surgical experience has many benefits including simplicity and accessibility, but may misrepresent actual experience because most operations are considered as a whole; unlike some colorectal operations, involvement in steps within many upper gastrointestinal (UGI) operations cannot be recorded. Methods Impact on training by the COVID-19 pandemic led to discussion and identification of cultural and logistical barriers to accurate recording of experience. To address these, a modification to enhance the current eLogbook system was developed by trainees and trainers at a university teaching hospital. An existing typology was used to deconstruct common UGI operations into their component steps, which can be recorded at this more detailed level. Results The modified deconstructed logbook concept is described using a worked example, which can be applied to any operation. We also describe the integration of a component-based training discussion into the surgical team brief and debrief; this complements the deconstructed logbook by promoting a training culture. Conclusions Using the described techniques, trainees of all levels can comprehensively and accurately describe their surgical experience. Senior trainees will benefit from recording complex operations which they are not expected to complete in their entirety, whilst less experienced trainees will benefit from the ability to record their involvement in more basic parts of operations. The suggested approach will reduce misrepresentation of experience, encourage proactive planning of training opportunities, and reduce the impact of crises such as pandemics on surgical training.

P-P40 Can trainees safely perform pancreatoduodenectomy? A systematic review, meta-analysis and risk-adjusted analysis of post-operative pancreatic fistula

Background The complexity of pancreaticoduodenectomy (PD) and fear of morbidity, particularly post-operative pancreatic fistula (POPF), can be a barrier to surgical trainees gaining operative experience. Objective to compare the POPF rate following PD by trainees or established surgeons. Methods A systematic review of the literature was performed using PRISMA guidelines, with differences in POPF rates after PD between trainee-led vs. consultant/attending surgeons pooled using meta-analysis. Variation in rates of POPF was further explored using risk-adjusted outcomes using published risk scores and CUSUM analysis in a retrospective cohort. Results Across 14 cohorts included in the meta-analysis, trainees tended towards a lower, but non significant rate of All-POPF (odds ratio [OR]: 0.77, p = 0.45) and clinically relevant (CR)-POPF (OR: 0.69, p = 0.37). However, there was evidence of case selection, with trainees being less likely to operate on patients with a pancreatic duct width <3mm (OR: 0.45, p = 0.05). Similarly, analysis of a retrospective cohort (N = 756 cases) found patients operated by trainees to have significantly lower predicted All-POPF (median: 20 vs. 26%, p < 0.001) and CR-POPF (7 vs. 9%, p = 0.020) rates than consultant/attending surgeons, based on pre-operative risk scores. After adjusting for this on multivariable analysis, the risks of All-POPF (OR: 1.18, p = 0.604) and CR-POPF (OR: 0.85, p = 0.693) remained similar after PD by trainee or consultant/attending surgeons. Conclusions PD, when performed by trainees, is associated with acceptable outcomes. There is evidence of case selection among patients undergoing surgery by trainees; hence, risk adjustment provides a critical tool for the objective evaluation of performance.

P-BN55 Results of the ARROW survey of anti-reflux practice in the UK

Background Gastro-oesophageal reflux disease (GORD) affects 10-20% of the population. Lifestyle modifications and medications such as proton pump inhibitors are generally well tolerated, however a variety of surgical and endoscopic interventions may be more suitable for well selected patients. Despite national guidelines and evidence from trials there is lack of consensus regarding the best approach to antireflux surgery (ARS). We designed a national audit (ARROW) to describe variation in UK clinical practice of ARS and adherence to clinical guidelines. Our audit was designed in two phases. First, a survey of national practice; Second, a prospective audit of adherence to available guidelines. Methods Survey questions were iteratively developed by the ARROW steering committee and an online tool was developed to gather survey responses and contact details for the audit phase. The final questionnaire consisted of 90 fields per surgeon and 57 fields per institution. Participants were enlisted through AUGIS, social media, personal contacts and the ROUX group of upper GI surgical trainees. The online tool was piloted in three centres. The protocol for the study was peer reviewed and published in Diseases of The Esophagus in January 2021 Results Survey responses were received from 151 surgeons at 57 institutions with a median of 40 cases annually and 4 surgeons/institution. Surgeons perform a median of 12(range 0-75) NHS cases and 6(range 0-75) private cases. 150/151 NHS surgeons perform some form of fundoplication for ARS, 4 surgeons perform LINX™, 4 STRETTA™ and 49 roux-en-y bypass for GORD. Fundoplication procedures performed in the UK include Nissen (111/151), Watson (39/151), Toupet (72/151) and Dor (61/151). 104 surgeons adjust the wrap performed according to clinical symptoms, manometry or both. 20/57 centres had no access to a benign MDT to discuss ARS. Conclusions ARS in the UK lacks standardised approaches that can be reliably compared and therefore improved most surgeons perform less than 20 cases a year. Our survey revealed differences in which investigations are considered mandatory, which procedures are available to whom and with what variations, and available resources to facilitate shared decision making for patients with GORD and ARS surgeons. Our audit phase (begun in April 2021) will establish current practice, compliance with clinical guidelines and inform improvement projects and randomised trials in the future.

Designing a synthetic simulator to teach open surgical skills for limb exploration in trauma: a qualitative study exploring the experiences and perspectives of educators and surgical trainees

Background Simulation is an important adjunct to aid in the acquisition of surgical skills of surgical trainees. The simulators used to adequately enable trainees to learn, practice and be assessed in surgical skills need to be of the highest standards. This study investigates the perceived requirements of simulation and simulators used to acquire skills in limb exploratory procedures in trauma. Methods Semi-structured interviews were conducted with an international group of 11 surgical educators and 11 surgical trainees who had experience with surgical simulation. The interviews focused on the perceptions of simulation, the integration of simulators within a curriculum and the features of a simulator itself. Interviews were recorded, transcribed and underwent thematic analysis. Results Analysis of the perspectives of surgical educators and surgical trainees on simulated training in limb trauma surgery yielded three main themes: (1) Attitudes to simulation. (2) Implementing simulation. (3) Features of an open skills simulator. The majority felt simulation was relevant, intuitive and a good way for procedure warmup and the supplementation of surgical logbooks. They felt simulation could be improved with increased accessibility and variety of simulator options tailored to the learner. Suggested simulator features included greater fidelity, haptic feedback and more complex inbuilt scenarios. On a practical level, there was a desire for cost effectiveness, easy set up and storage. The responses of the educators and the trainees were similar and reflected similar concerns and suggestions for improvement. Conclusion There is a clear positive appetite for the incorporation of simulation into limb trauma training. The findings of this will inform the optimal requirements for high quality implementation of simulation into a surgical trauma curriculum and a reference to optimal features desired in simulator or task trainer design.

The PASS Course: Practical Anatomy and Surgical Skills Course as a Pragmatic Primer for Senior Medical Students Pursuing Surgical Residency

The senior year of undergraduate medical education has been scrutinized for lacking emphasis from educators and value for students. Surgical residency program directors and medical students have reported different sets of perceived weaknesses as surgical trainees enter residency. With this in mind, we developed a novel rotation for senior medical students pursuing surgical residency. The rotation incorporates practical didactics, robust skill and simulation training, and an enriching anatomy experience that entails dissections and operations on embalmed and fresh tissue cadavers. To our knowledge, this is the first reported formal training experience for medical students that involves working with fresh tissue cadavers, which have been described as effective models for live human tissue in the operating room. We describe our multifaceted curriculum in detail, discuss its organization, and elaborate on its potential value. We also provide detailed explanations of the curriculum components so that other surgical educators may consider adopting them.