Vanessa N. Palter

: To develop and validate an ex vivo comprehensive curriculum for a basic laparoscopic procedure. : Although simulators have been well validated as tools to teach technical skills, their integration into comprehensive curricula is lacking. Moreover, neither the effect of ex vivo training on learning curves in the operating room (OR), nor the effect on nontechnical proficiency has been investigated. : This randomized single-blinded prospective trial allocated 20 surgical trainees to a structured training and assessment curriculum (STAC) group or conventional residency training. The STAC consisted of case-based learning, proficiency-based virtual reality training, laparoscopic box training, and OR participation. After completion of the intervention, all participants performed 5 sequential laparoscopic cholecystectomies in the OR. The primary outcome measure was the difference in technical performance between the 2 groups during the first laparoscopic cholecystectomy. Secondary outcome measures included differences with respect to learning curves in the OR, technical proficiency of each sequential laparoscopic cholecystectomy, and nontechnical skills. : Residents in the STAC group outperformed residents in the conventional group in the first (P = 0.004), second (P = 0.036), third (P = 0.021), and fourth (P = 0.023) laparoscopic cholecystectomies. The conventional group demonstrated a significant learning curve in the OR (P = 0.015) in contrast to the STAC group (P = 0.032). Residents in the STAC group also had significantly higher nontechnical skills (P = 0.027). : Participating in the STAC shifted the learning curve for a basic laparoscopic procedure from the operating room into the simulation laboratory. STAC-trained residents had superior technical proficiency in the OR and nontechnical skills compared with conventionally trained residents. (The study registration ID is NCT01560494.).

To develop and validate a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery. Simulators have been shown to be viable systems for teaching technical skills outside the operating room; however, integration of simulation training into comprehensive curricula remains a major challenge in modern surgical education. Currently, no curricula have been described or validated for advanced laparoscopic procedures. This prospective, single-blinded randomized controlled trial allocated 25 surgical residents to receive either conventional residency training or a comprehensive training curriculum for laparoscopic colorectal surgery. The curriculum consisted of proficiency-based psychomotor training on a virtual reality simulator, cognitive training, and participation in a cadaver lab. The primary outcome measure in this study was surgical performance in the operating room. All participants performed a laparoscopic right colectomy, which was video recorded and assessed using 2 previously validated assessment tools. Secondary outcome measures were knowledge relating to the execution of the procedure, assessed with a multiple-choice test, and technical performance on the simulator. Curricular-trained residents demonstrated superior performance in the operating room compared with conventionally trained residents (global score 16.0 [14.5-18.0] versus 8.0 [6.0-14.5], P = 0.030; number of operative steps performed 16.0 [12.5-17.5] versus 8.0 [6.0-14.5], P = 0.021; procedure-specific score 71.1 [54.4-81.6] versus 51.1 [36.7-74.4], P = 0.122). Curricular-trained residents scored higher on the multiple-choice test (10 [9-11] versus 7.5 [5.3-7.5], P = 0.047), and outperformed conventionally trained residents in 7 of 8 tasks on the simulator. Participation in a comprehensive ex vivo training curriculum for laparoscopic colorectal surgery results in improved technical knowledge and improved performance in the operating room compared with conventional residency training. Reg. ID#NCT 01371136.

Laparoscopic colorectal surgery is considered an advanced minimally invasive procedure with a long, variable learning curve. Developing an evaluation tool is essential to ensure that individuals reach a certain level of competence prior to performing this procedure independently. To achieve standardization and wide implementation, an assessment tool must be reflective of practice across many institutions. The purpose of this study is to validate two procedure-specific evaluation tools for laparoscopic colorectal surgery that were developed using innovative consensus methodology. Two procedure-specific rating scales for laparoscopic right and sigmoid colectomy were created using the Delphi method. Nine novice and nine expert laparoscopic sigmoid colectomy videos were prospectively collected, and nine novice and ten expert laparoscopic right colectomy videos were recorded. The experts rated the videos using the procedure-specific technical skills evaluation tool for either laparoscopic right colectomy or laparoscopic sigmoid colectomy. There were statistically significant differences between the expert and novice scores on the laparoscopic right colectomy evaluation tool: the median score of novices was 63.8% and the expert score was 73.1% (p = 0.02). Similarly, there was a significant difference between the median novice score on the sigmoid tool (58.6%) compared with the median expert score (70.7%) (p = 0.003). Cronbach’s alpha was 0.82 for the right colectomy evaluation tool and 0.79 for the sigmoid rating scale. The procedure-specific evaluation tools for laparoscopic right and sigmoid colectomy demonstrate strong reliability and construct validity, and have the potential to be used for technical skills assessment and feedback.

Background: The unique skill set required for minimally invasive surgery has in part contributed to a certain portion of surgical residency training transitioning from the operating room to the surgical skills laboratory. Simulation lends itself well as a method to shorten the learning curve for minimally invasive surgery by allowing trainees to practice the unique motor skills required for this type of surgery in a safe, structured environment. Although a significant amount of important work has been done to validate simulators as viable systems for teaching technical skills outside the operating room, the next step is to integrate simulation training into a comprehensive curriculum. Objectives: This narrative review aims to synthesize the evidence and educational theories underlining curricula development for technical skills both in a broad context and specifically as it pertains to minimally invasive surgery. Findings: The review highlights the critical aspects of simulation training, such as the effective provision of feedback, deliberate practice, training to proficiency, the opportunity to practice at varying levels of difficulty, and the inclusion of both cognitive teaching and hands-on training. In addition, frameworks for integrating simulation training into a comprehensive curriculum are described. Finally, existing curricula on both laparoscopic box trainers and virtual reality simulators are critically evaluated.

Surgical training in the operating room includes acquiring technical skills and cognitive knowledge. Technical skills training on simulated models has been shown to improve technical performance in the operating room, and may also enhance the acquisition of other skills by freeing cognitive capacity. This has yet to be investigated. We conducted a single-blinded randomized controlled trial to assess the effect of ex vivo technical skills training on cognitive learning in the operating room. Eighteen novice surgical residents were randomized to 2 groups. All participants were taught the basics of fascial closure and performed 1 closure on a low fidelity synthetic model. Residents in the intervention group practiced on the models until technical proficiency was reached. Residents in the control group had no further contact with the models. All residents then performed a fascial closure on a patient in the operating room while listening to a script that contained relevant clinical information. A validated evaluation tool was used to assess the technical merit of the closure. Finally, all participants completed a multiple-choice test designed to test the information retained from the script. The technical performance of the ex vivo trained group was significantly higher than that of the untrained group (P = 0.04). The ex vivo trained group also performed significantly better on the cognitive retention test (P = 0.03). Technical skills training using a low fidelity synthetic simulator resulted in improved technical performance in the operating room, and enhanced the ability of residents to attend to cognitive components of surgical expertise.