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Background: Previous studies using simulation-based curricula have focused largely on technical skills. We developed a set of simulation-based modules that focus on intraoperative decision making. The objective of this study was to conduct a faculty evaluation of: (1) the usefulness of 4 newly developed, simulation-based modules; (2) the curricular need to train and assess intraoperative decision making skills of the residents; and (3) potential for resident benefit. Methods: Simulation-based modules were developed using a cognitive task analysis (CTA) framework. The CTA framework involved faculty interviews focusing on 4 operative tasks that span a range of complexity: (1) creation of small and large bowel stoma, (2) laparoscopic ventral hernia repair, (3) pancreaticojejunostomy, and (4) lymph node biopsy during a mediastinoscopy. An experienced psychologist conducted task-specific, one-on-one interviews with fellowship-trained specialists who perform these operations in their practice. Two faculty were interviewed for each procedure. The interviews lasted a minimum of 1 hour and focused on critical decisions, error prevention, error recognition, and error rescue strategies. The coded interview summaries were used as development guides for the simulation-based learning modules. Each module included locally developed physical models for the simulated operative tasks combined with oral and paper-based questions. The physical models were fabricated in such a way that simulated operative tasks could be performed using standard surgical instruments. To assess the newly developed simulation-based modules, 8 volunteer faculty (50% overlap with the interview pool) participated in a simulation-based exercise during a one-on-one session and then completed an 8-item survey cast on a 5-point Likert agreement scale (1 = strongly disagree, 5 = strongly agree). One of the items was worded negatively to ensure internal consistency. An independent observer recorded faculty session times and assessed faculty engagement in the task (1 = not engaged, 5 = extremely engaged). Results: On average, faculty spent 60 minutes completing each simulation-based exercise. Over 80% of this time was spent performing the operative tasks as they would during a real-life procedure. Mean engagement rating was 4.9 (maximum 5.0, SD = 0.3). Survey results show strong agreement on the importance of training and assessing intraoperative decision making, and that residents would likely benefit from the simulation-based modules. Conclusion: We developed 4 high-fidelity simulation-based modules to assess intraoperative decision making. Faculty agree strongly on the importance and need for additional modules. [Copyright &y& Elsevier]

Background: Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR. Methods: A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P < .05 = statistical significance). Results: The mean age of this cohort was 52 years (range, 18–85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified. Conclusion: Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection. [ABSTRACT FROM AUTHOR]