A Simulation-Based Curriculum Can Be Used to Teach Open Intestinal Anastomosis

doi:10.1016/j.jss.2010.08.009

Journal of Surgical Research

Volume 172, Issue 1, January 2012, Pages 53-58

https://doi.org/10.1016/j.jss.2010.08.009 Get rights and content

Background

Simulation is a technique commonly used to teach technical skills such as those necessary in laparoscopic surgery. Curricula with objective, validated metrics rating performance are widely used. Simulations to develop and assess skills necessary for open surgical procedures are less common. We hypothesized that a curriculum designed to teach the skills necessary to perform open laparotomy and bowel anastomosis would result in improved knowledge of the procedure steps, increased technical skills, and improved confidence in novice surgeons.

Methods

A simulation-based curriculum designed to teach open laparotomy and bowel anastomosis was developed. Eleven surgical interns participated in the 6-wk curriculum. Written surveys regarding confidence in the knowledge and ability to perform these procedures were administered before and after the curriculum. Videos of the first six subjects were created on the first and final repetition of the simulation. An Objective Assessment of Technical Skills (OSATS) instrument was used to evaluate each video by two independent, blinded reviewers.

Results

Subjects demonstrated significantly improved OSATS scores for skills and knowledge in seven of nine domains assessed upon completion of the curriculum. Subject confidence in laparotomy and bowel anastomosis skills improved significantly.

Conclusion

A structured, simulation-based curriculum designed to teach laparotomy and hand-sewn bowel anastomosis skills is effective and increases participant confidence. Further study is required to determine whether simulation results in improved performance in the operating room.

Introduction

Surgical training has undergone significant changes in recent years. Contemporary factors have challenged the traditional apprenticeship model popularized by Dr. William Halstead. The rapid evolution of new surgical techniques and technologies, the advent of the 80-h workweek, and an increased public scrutiny on outcomes and patient safety are modern issues that must be addressed in surgical residencies. Simulation-based training allows educators to create curricula designed to lead to the development of a specific skill or set of skills in a measurable and reproducible manner. Surgical skills acquisition through simulation is more deliberate and efficient than the old method of 5 y of exposure to a volume of surgical cases.

Laparoscopic surgery is particularly well-suited to simulation training. Laparoscopic training curricula in low fidelity video trainers have been validated and demonstrated to lead to the development of surgical skills that translate into the operating theater 1, 2. Simulation as a method to develop and teach open surgical skills is less commonly described. We hypothesized that a structured, simulation-based curriculum to teach laparotomy opening, closing, and hand-sewn bowel anastomosis would result in improved knowledge of procedural steps, enhanced technical skill, and improved confidence in the ability to perform these procedures in first year general surgery residents.

Section snippets

Materials and Methods

Eleven categorical first-year general surgery residents from two consecutive classes participated in a standardized curriculum designed to develop the cognitive and manual skills necessary to make an abdominal fascia incision, perform a hand-sewn bowel anastomosis, and close the laparotomy. Didactic content included anatomic illustrations and a course manual describing the technical steps for laparotomy and hand-sewn end-to-end bowel anastomosis. The material was original to this curriculum but

Results

Subjects demonstrated significantly improved global rating scores for technical skills and knowledge used in laparotomy and hand-sewn bowel anastomosis in seven of the nine domains evaluated with the OSATS tool. There were statistically significant improvements in the domains of respect for tissues, efficiency of time and motion, instrument handling, appropriate use of assistant, flow of operation and forward planning, knowledge of the procedure, and quality of final product. There was no

Discussion

We have demonstrated that a structured, simulation-based curriculum designed to teach laparotomy opening and closing, hand-sewn bowel anastomosis, and skin closure is effective in first-year general surgery residents. Using a modified OSATS tool, subjects were shown to be more knowledgeable and technically proficient in laparotomy and hand-sewn bowel anastomosis techniques upon completion of this curriculum. Junior resident confidence in the performance of these skills and procedures was

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Cited by (16)

Hand Sewn Anastomosis Skill Acquisition and In Vivo Transfer Using 3D-Printed Small Bowel Simulator
2023, Journal of Surgical Research
General surgery residents need to master the hand-sewn bowel anastomosis (HSBA) technique. However, practice opportunities outside of the operating room are rare, and commercial simulators are often costly. The objective of this study is to assess the efficacy of a new, affordable silicone small bowel simulator, made with a three-dimensional (3D) printed mold, as a training tool to learn this technique.
This was a single-blinded pilot randomized controlled trial comparing two groups of eight junior surgical residents. All participants completed a pretest using an inexpensive, custom developed 3D-printed simulator. Next, participants randomized to the experimental group practiced the HSBA skill at home (eight sessions), while those randomized to the control group did not receive any hands-on practice opportunities. A posttest was done using the same simulator as for the pretest and practice sessions, and the retention-transfer test was performed on an anesthetized porcine model. Pretests, posttests and retention-transfer tests were filmed and graded by a blinded evaluator using assessments of technical skills, quality of final product, and tests of procedural knowledge.
The experimental group significantly improved after practicing with the model (P = 0.01), while an equivalent improvement was not noted in the control group (P = 0.07). Moreover, the experimental group's performance remained stable between the posttest and the retention-transfer test (P = 0.95).
Our 3D-printed simulator is an affordable and efficacious tool to teach residents the HSBA technique. It allows development of surgical skills that are transferable to an in vivo model.
Acquisition and retention of surgical skills taught during intern surgical boot camp
2021, American Journal of Surgery
Surgical residencies have implemented boot-camps for early acquisition of basic technical skills for interns. However, educators worry that retention is poor. We hypothesized that a structured boot-camp curriculum would improve skills.
Interns underwent eight boot-camp sessions at the beginning of residency. Interns completed pre-, post-boot-camp, and end-of-year skills assessments, as well as post-boot camp and end-of-year porcine procedure labs. Proficiency was measured on a 5-point scale and by completion time.
After boot-camp, interns improved all domains of knot-tying. Median time decreased for skin-closure (8.3 vs 9.9 min, p < 0.01), peg transfer (57 vs 87 s, p < 0.01), intracorporeal (178 vs 300 s, p < 0.01), and extracorporeal knot-tying (140 vs 259 s, p < 0.01). At the end-of-year assessment, interns exhibited retention of all skills and improved in knot-tying and central line skills. During the retention porcine lab, interns progressed basic but not complex skills.
An eight-week boot-camp effectively improved technical skills among surgery interns. Interns retained all skills and improved upon techniques frequently practiced during intern year.
Current Status of Technical Skills Assessment Tools in Surgery: A Systematic Review
2020, Journal of Surgical Research
Citation Excerpt :
Forty studies did not specify a field, and three assessed medical students only. OSATS was the most frequently used tool (n = 137, 45.2%)14-50,51-90,91-125,126-150 (Table 1). Test content was assessed by 68 (50%) studies, and the response process was seen in 61 (45%).
Tools for assessment of technical skills are a crucial part of surgical education. They provide trainees with quantitative feedback highlighting both proficiency and areas for improvement. For this to be relevant to day-to-day practice, the tools used have to be validated and relevant to each surgical situation. This study aims to evaluate the validity of assessment tools used within surgery.
Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted searching the MEDLINE and Embase databases (International Prospective Register of Systematic Reviews: CRD42018104674). Studies utilizing any assessment tool in any surgical specialty were included. Messick's criteria were used for literature evaluation, and the Modified Educational Oxford Centre for Evidence-Based Medicine was used to assess levels of recommendation.
A total of 303 studies and 76 tools were included. The most commonly used tool was Objective Structured Assessment Tool Skills (OSATS; n = 137, 45.2%). OSATS was used in conjunction with another tool or tools in an additional 55 studies (18.2%). Seven further tools were used in at least 3 studies. A total of five studies evaluated contained all five aspects of Messick's validity.
There are several widely validated tools for assessing technical skills, the most common of which is OSATS. There is an emerging trend for crowdsourcing as a quick, cheap method for assessment of technical skills. This technique has been validated using both GEARS and GOALS. Numerous tools were found to be used only once and demonstrate a tendency for units to create their own tools for a specific task or specialty.
Comparison of faculty versus structured peer-feedback for acquisitions of basic and intermediate-level surgical skills
2019, American Journal of Surgery
Video feedback and faculty feedback has been shown to improve surgical performance; however, consistent access to faculty is challenging. We studied the utility of structured peer-feedback (PF) compared to faculty-feedback (FF) during acquisition of basic and intermediate surgical skills.
Two randomized non-inferiority trials were conducted with 1st (n = 30) and 2nd year (n = 29) medical students learning skin-lesion excision and closure (S), and single-layer hand-sewn bowel anastomosis (B), respectively. Five attempts were performed. PF participants used an Objective Structured Assessment of Technical Skills tool to guide feedback. Blinded raters assessed video-recorded performance, time and Integrity of the completed task were also assessed.
For both tasks performance by PF was comparable to FF (P = 0.111). Both groups improved significantly: performance (B:P < 0.0001, S:P = 0.035), time (B:P = 0.043, S:P < 0.0001) and integrity (B:P < 0.0001, S:P < 0.032).
Structured peer-feedback is equivalent to faculty-feedback in the acquisition of basic and intermediate surgical skills, giving students freedom to practice independently.
Experience of General Surgery Residents in the Creation of Small Bowel and Colon Anastomoses
2016, Journal of Surgical Education
Citation Excerpt :
A tool has been developed and validated for the assessment of competence in creating simulated IAs in the laboratory called the objective structured assessment of technical skills method.35 It has been shown that including the creation of HS IAs in the simulation curriculum is effective in acquiring the necessary skills and in gaining confidence with the relevant techniques.36,37 However, in addition to simulation, GSRs should be exposed to both elective and emergency surgery cases for learning and practicing in live clinical scenarios as much as possible.
With the introduction of stapling devices (SDs), the proportion of hand-sewn (HS) intestinal anastomoses (IAs) has declined. As more IAs are constructed with SDs, there are fewer opportunities for general surgery residents (GSRs) to acquire the skills for HS techniques during their training.
Data for this study were extracted from an existing database of all IAs performed at the Department of Surgery of the Morristown Medical Center since 2003. For the purposes of this study, a 5.5-year timeframe was used between July 2006 and 2011, which contained 1659 IA operations on adult patients with resident involvement. GSRs of the 5-year general surgery residency program were grouped by postgraduate year (PGY) for further analysis.
The number of all IAs created by each resident during the 5-year training was 67.2 on average. Most of these operations were done in the last 2 years of the training: 45.1% of all IAs in PGY5 and 37.3% of all IAs in PGY4. Of all, 1659 IAs performed in the study period, 711 (42.9% of total) were done laparoscopically and 948 (57.1% of all IAs) were done as open operations. Laparoscopic operations had a proportionally higher rate of SD use when compared to open cases (90.9% vs 82.4%). On average, each resident constructed 9.4 HS IAs (13.98% of all IAs) and 57.8 SD IAs (86.02% of total). Out of all anastomoses, ostomy reversals (30.7%) had the highest percentage of HS suturing followed by right colectomies (27.5%), ileal pouch-anal anastomoses and total colectomies and proctocolectomies (23.3%), small bowel resection (17.0%), and left colectomies (5.5%). Regardless of the location of the operation, stapled and sutured anastomoses had similar outcomes measured by the rate of anastomotic leaks. Residents used significantly more SDs in the creation of anastomoses than HS suturing in the PGY3, PGY4, and PGY5 years. We also documented that attending surgeons who are older more often used HS suturing than their younger colleagues when creating IAs.
The experiences of GSRs in IA operations are heavily weighted toward the use of SDs. There are select cases, however, when HS suturing can have an advantage over stapler use in anastomosis creation. Therefore, we believe that GSRs should continue learning, perfecting, and using the both techniques.
Virtual reality training in laparoscopic surgery: A systematic review & meta-analysis
2016, International Journal of Surgery
Laparoscopic surgery requires a different and sometimes more complex skill set than does open surgery. Shortened working hours, less training times, and patient safety issues necessitates that these skills need to be acquired outside the operating room. Virtual reality simulation in laparoscopic surgery is a growing field, and many studies have been published to determine its effectiveness.
This systematic review and meta-analysis aims to evaluate virtual reality simulation in laparoscopic abdominal surgery in comparison to other simulation models and to no training.
A systematic literature search was carried out until January 2014 in full adherence to PRISMA guidelines. All randomised controlled studies comparing virtual reality training to other models of training or to no training were included. Only studies utilizing objective and validated assessment tools were included.
Thirty one randomised controlled trials that compare virtual reality training to other models of training or to no training were included. The results of the meta-analysis showed that virtual reality simulation is significantly more effective than video trainers, and at least as good as box trainers.
The use of Proficiency-based VR training, under supervision with prompt instructions and feedback, and the use of haptic feedback, has proven to be the most effective way of delivering the virtual reality training. The incorporation of virtual reality training into surgical training curricula is now necessary. A unified platform of training needs to be established. Further studies to assess the impact on patient outcomes and on hospital costs are necessary. (PROSPERO Registration number: CRD42014010030).

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Association for Academic SurgeryA Simulation-Based Curriculum Can Be Used to Teach Open Intestinal Anastomosis

Background

Methods

Results

Conclusion

Introduction

Section snippets

Materials and Methods

Results

Discussion

J Surg Res

J Gastrointest Surg

J Gastrointest Surg

Gastrointest Endosc

J Am Coll Surg

Association for Academic Surgery
A Simulation-Based Curriculum Can Be Used to Teach Open Intestinal Anastomosis