Anthony Gerald Gallagher

Objectives: To evaluate the association between objectively assessed intraoperative surgical performance and postoperative functional outcomes following robot‐assisted radical prostatectomy (RARP). Patients/Subjects and Methods: Prospectively collected data from 100 patients undergoing bilateral nerve‐sparing RARP by seven experienced robotic surgeons were analysed. To control for age‐related confounding, a subgroup of 66 subjects was selected from the initial cohort using age‐matching. These patients, all of whom were preoperatively potent, were identified from an audited outcomes registry with complete video recordings. In all, 14 trained surgeons trained to score the recordings using validated RARP‐specific metrics for procedure steps, errors, critical errors, and nerve‐sparing phase errors. Results: There were no significant pre‐ or postoperative differences in demographic or clinical variables between patients with good or poor outcomes. The mean inter‐rater reliability of video assessments was high (0.91). There were no significant differences in the number of steps completed or critical errors made. Intraoperative performance in cases resulting in erectile dysfunction at 12 months was characterised by 43% more total errors and 67% more neurovascular bundle (NVB) dissection errors ( P < 0.001) compared to cases with good functional outcomes. Age‐matched analysis confirmed differences of 31–54% ( P < 0.001). The number of intraoperative errors, particularly during NVB dissection, was strongly associated with clinical outcomes ( P = 0.01–0.008). Conclusions: The objectively assessed intraoperative performance of the surgeon strongly predicted the clinical outcome of the procedure at 1 year. The more errors the surgeon made the more likely the patient was to have erectile dysfunction at 12 months.

Aims: Cardiac Implantable Electronic Devices (CIED) training for novice implanters typically occurs in vivo, varies across countries/institutions, and results in inconsistent skill levels. Proficiency-Based Progression (PBP) simulation training—requiring attainment of expert-derived performance benchmarks before clinical practice—reduced procedural errors by 61–77% compared with traditional simulation-based training (SBT) in randomised simulation trials. This study aimed to quantify clinical skill transfer in CIED implantation for the first time, comparing in vivo deviations from expert-agreed optimal technique in early-career implanters previously randomised to PBP versus SBT. Methods and results: Prospective observational cohort study following participants from a prior multinational randomised simulation trial to assess transfer of training to clinical practice. Early-career implanters (≥20 prior pacemaker/defibrillator cases; limited CRT first-operator experience) reported the implant technique they applied in their first two routine clinical cases within 30 days of training, using a validated standardised performance metrics form assessing surgical and lead implantation steps. The primary outcome was the mean percentage of deviations from optimal technique per participant. Of 30 randomised participants, 21 (70%) submitted 42 case reports (10 PBP, 11 SBT). Baseline characteristics were similar and case complexity did not differ between groups (p = 0.43). PBP trainees demonstrated 60% fewer procedural deviations than SBT trainees (mean [SD], 5.8% [3.8%] vs 14.4% [9.1%]; p = 0.013). Conclusion: Metrics-based PBP training was associated with significantly fewer procedural deviations from optimal CIED implant technique during early clinical practice compared with traditional simulation. These findings support benchmark-based simulation as a strategy to improve early clinical skill transfer in cardiac electrophysiology.

The rapid expansion of interventional electrophysiology (EP) and cardiac implantable electronic device (CIED) therapies has outpaced the capacity of traditional apprenticeship-based training to deliver standardized, equitable, and patient-safe skill acquisition across Europe. This scientific statement of European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC) synthesizes the current landscape of digitally assisted learning for EP/CIED, provides a structured framework for implementation, and defines the responsibilities of scientific societies in establishing trustworthy, competency-based pathways. The document first reviews the technical principles and available digital modalities, emphasizing alignment of tool selection with learning objectives and staged progression. It then contrasts these capabilities with real-world uptake, highlighting fragmented access and strong reliance on industry-mediated training, alongside the emergence of neutral access models such as the EHRA Simulation Village. A central suggestion is the adoption of proficiency-based progression supported by protocolized evaluation: predefined and validated performance metrics, benchmarking against expert standards, deliberate practice with structured feedback, and summative assessment prior to patient procedures. Key implementation challenges include resource disparities and geographic inequities, limits in simulation fidelity for team-based and contextual decision-making, governance of industry relationships, and the need for protected educational time. Pragmatic solutions include tiered certification tracks, hybrid models combining digital and supervised clinical training, regional simulation hubs, minimum simulator specifications, ongoing curriculum updates, and coordinated stakeholder collaboration. Priority research needs are defined around clinical outcome validation, optimal curriculum design, technology development, and implementation science.

Study objective The study aimed to develop procedural performance metrics for robot-assisted total laparoscopic hysterectomy (RATLH) and to establish face and content validity through a Delphi consensus meeting. Design A core metrics team comprising three highly experienced gynaecologists in RATLH and a behavioural scientist developed the metrics. Setting Two modified Delphi consensus meetings took place as a face-to-face and online. Patients The final metrics were discussed by 28 experts in RATLH from 13 different countries. Interventions The core metrics team performed a detailed task deconstruction of the RATLH procedure. To ensure a comprehensive representation of technique and clinical practice across both the US and Europe, a consensus meeting was also conducted with European clinicians. Measurements and main results Initially, performance metrics consisting of 20 Phases, 110 steps, 119 errors, and 54 critical errors were identified to characterize the RATLH procedure. During the Delphi meetings, these were discussed and modified. The outcome of the meeting was consensus on 20 Phases of the procedure, with 116 Steps (8 added, 2 deleted), 134 Errors (19 were added and 4 were deleted), and 56 Critical Errors (2 added). A total number of 41 general edits were performed with 100% consensus. Conclusions This study presents the first comprehensive metric-based characterization of a standardized approach to RATLH, validated by expert consensus using a structured methodology that comprises operative procedure Steps, Errors, and Critical Errors. The next phase will evaluate reliability and the construct validity of the agreed metrics.

Cardiac implantable electronic devices (CIEDs) are widely used to manage rhythm disorders. However, implanters’ training still follows an apprenticeship model, conducted in vivo from the outset, with wide institutional variability and lacking objective performance criteria to assess competence. Using objective validated metrics, this study evaluated procedural skills of early-career operators licensed to independently perform implantations and explored potential benefits of additional simulation-based training. Fifteen CIED implanters from six European countries underwent a three-task simulation assessment: (1) virtual reality dual-chamber pacemaker lead implantation scored using validated procedural metrics; (2) suture selection for lead fixation; and (3) knot-tying tested for security via tensiometer. Primary outcomes included total procedural errors (All-Errors), correct suture choice, and knot integrity. Performance was benchmarked against expert-defined proficiency standards. A supplementary analysis compared results with prior cohorts trained via traditional simulation-based training (SBT) or proficiency-based progression (PBP) approach. Participants made a median of 7.0 All-Errors (IQR 4.0–8.5) in the implant task, with only 20% meeting proficiency criteria. Correct suture selection occurred in 73%, and 67% tied secure knots. No significant correlation was found between implant experience and All-Errors rate. Compared to study participants, PBP-trained peers made 76% fewer errors (p < 0.001), while SBT training offered no significant advantage. Despite being licensed first operators, most early-career CIED implanters did not meet proficiency benchmarks. These findings highlight limitations in current training and certification. Proficiency-Based Progression may address these gaps by ensuring objectively verified readiness on simulation before in-vivo practice. Future studies should evaluate its impact on clinical outcomes. Graphical abstract

Introduction: Training on cryoballoon-based ablation for Atrial fibrillation (CBA-AF) procedures usually takes place in-vivo and methods vary across countries/institutions. Aims: We sought to identify objective performance metrics that best characterize a reference approach to CBA for AF procedure and obtain support for face and content validity from procedure experts through a modified Delphi meeting. Methods: During a series of five face-to-face and two online meetings, a core Metrics Team of three CBA for AF procedure experts, two biomedical engineers and a senior behavioral scientist performed a detailed task deconstruction of a CBA-AF. They identified performance metrics that constitute an optimal approach for performance of the procedure for training purposes. The metrics were then subjected to an in-person modified Delphi panel meeting with 16 international procedure experts. Results: 12 procedure Phases, with 239 procedure Steps, 113 Errors and 74 Critical Errors were identified. After the Modified Delphi process there were 244 procedure Steps 111 Errors and 91 Critical Errors. Metrics before and after Delphi were highly correlated (r = 0.976 to 0.98, p < 001). Only the increase in Critical Errors was statistically significant (Z = -2.257, p = 0.024). After agreed edits, there was 100% Delphi panel consensus on the metrics. Conclusions: Performance metrics that accurately characterize a reference approach to CBA-AF were developed by a core group of experts. These metrics were endorsed by an international panel of very experienced peers. Reliable and valid metrics underpin effective, quality-assured, structured procedural training on CBA-AF.

BACKGROUND AND OBJECTIVES: External ventricular drain (EVD) placement is often performed freehand, a technique subpar to accurate yet impractical image-guided methods, yielding optimal placement in only 70%. The aim of this study was to address shortcomings in EVD placement and image guidance technologies by implementing high-accuracy augmented reality (AR) guidance. METHODS: We conducted a prospective clinical pilot study to assess feasibility, safety, and clinical performance of EVD placement using a standalone AR headset equipped with high-accuracy inside-out infrared tracking and software addressing EVD placement. Placement quality was reported using a newly defined extended modified Kakarla scale, and dichotomized into clinically relevant outcome parameters. Results were compared with a nonconcurrent freehand control group using one-sided Fisher exact tests. RESULTS: Eleven AR-guided EVD placements were performed, achieving functional placement in all cases on the first attempt, vs 7 (64%) in the control group (P = .045); successful placement in 9 (82%) vs 5 (45%); optimal in 8 (73%) vs 3 (27%) (P = .043); suboptimal in 2 (18%) vs 5 (45%); and failed in 0 vs 1 (9%). No AR-guided placements required revision, whereas the freehand group had a 36% reintervention rate (P = .045). Procedure-related complications occurred in 2 AR-guided cases (18%), vs 5 (45%) freehand (all post-reintervention). CONCLUSION: This study presents the first clinical use case of EVD placement using high-accuracy AR guidance contained in a standalone head-worn navigation system. Safe and reliable outcomes using a validated pipeline were demonstrated, eliminating stick-and-poke attempts and resulting in improved quality, increased single attempt success rates, and reduced revision and complication rates. Based on these results, a multicenter randomized controlled trial will be initiated.

Aims: In cardiac device implantation, having both surgical skills and ability to manipulate catheter/lead/wire is crucial. Few cardiologists, however, receive formal surgical training prior to implanting. Skills are mostly acquired directly on-the-job and surgical technique varies across institutions; suboptimal approaches may increase complications. We investigated how novel proficiency-based progression (PBP) simulation training impacts the surgical quality of implantations, compared to traditional simulation (SIM) training. Methods and results: In this international prospective study, novice implanters were randomized (blinded) 1:1 to participate in a simulation-based procedure training curriculum, with proficiency demonstration requirements for advancing (PBP approach) or without (SIM). Ultimately, trainees performed the surgical tasks of an implant on a porcine tissue that was video-recorded and then scored by two independent assessors (blinded to group), using previously validated performance metrics. Primary outcomes were the number of procedural Steps Completed, Critical Errors, Errors (non-critical), and All Errors Combined. Thirty novice implanters from 10 countries participated. Baseline experiences were similar between groups. Compared to SIM-trained, the PBP-trained group completed on average 11% more procedural Steps (P < 0.001) and made 61.2% fewer Critical Errors (P < 0.001), 57.1% fewer Errors (P = 0.140), and 60.7% fewer All Errors Combined (P = 0.001); 11/15 (73%) PBP trainees demonstrated the predefined target performance level vs. 3/15 SIM trainees (20%) in the video-recorded performance. Conclusion: Proficiency-based progression training produces superior objectively assessed novice operators’ surgical performance in device implantation compared with traditional (simulation) training. Systematic PBP incorporation into formal academic surgical skills training is recommended before in vivo device practice. Future studies will quantify PBP training’s effect on surgery-related device complications.

Robot-assisted partial nephrectomy (RAPN) is a complex and index procedure that urologists need to learn how to perform safely. No validated performance metrics specifically developed for a RAPN training model (TM) exist. A Core Metrics Group specifically adapted human RAPN metrics to be used in a newly developed RAPN TM, explicitly defining phases, steps, errors, and critical errors. A modified Delphi meeting concurred on the face and content validation of the new metrics. One hundred percent consensus was achieved by the Delphi panel on 8 Phases, 32 Steps, 136 Errors and 64 Critical Errors. Two trained assessors evaluated recorded video performances of novice and expert RAPN surgeons executing an emulated RAPN in the newly developed TM. There were no differences in procedure Steps completed by the two groups. Experienced RAPN surgeons made 34% fewer Total Errors than the Novice group. Performance score for both groups was divided at the median score using Total Error scores, into HiError and LoError subgroups. The LowErrs Expert RAPN surgeons group made 118% fewer Total Errors than the Novice HiErrs group. Furthermore, the LowErrs Expert RAPN surgeons made 77% fewer Total Errors than the HiErrs Expert RAPN surgeons. These results established construct and discriminative validity of the metrics. The authors described a novel RAPN TM and its associated performance metrics with evidence supporting their face, content, construct, and discriminative validation. This report and evidence support the implementation of a simulation-based proficiency-based progression (PBP) training program for RAPN.

Introduction: We evaluated the intra-operative situational awareness (as measured with detection accuracy and latency) capacity of interventional cardiologists during the performance of physics-based virtual reality simulation of a coronary angiography procedure. Methods: Using a between groups repeated measures design we assessed experienced and mid-level interventional cardiologists (ICs) using eye tracking glasses and physics-based virtual reality simulation. We assessed their intra-operative procedure performance errors, situation awareness, and attentional capacity as they performed a coronary angiogram. The main outcomes were intra-operative performance errors, situation awareness as measure of the operators capacity and latency to detect and correctly respond to salient visual stimuli. Results: We showed that experienced cardiologists had considerably better situation awareness. They demonstrated faster stimulus identification and report latencies (4.5 times quicker, p < 0.001). Furthermore, trainees detection latency scores strongly predicted total technical error scores (r = 0.93). Conclusions: This study showed that experienced ICs had a greater capacity to detect, recognise, and make judgements about deviations from optimal performance intra-operatively. The results from this study almost certainly apply to all image guided medical interventional procedures and have important patient safety implications.