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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2006.03.003 Byline: E. Matt Ritter (a)(b), David A. McClusky (a), Anthony G. Gallagher (a), Lars Enochsson (c), C. Daniel Smith (a) Keywords: Abilities; Flexible endoscopy; Objective assessment; Simulation; Visuospatial abilities Abstract: Trainees acquire endoscopic skills at different rates. Fundamental abilities testing could predict the amount of training required to reach a performance goal on a virtual-reality simulator. Author Affiliation: (a) Emory Simulation, Training, and Robotics (E*STAR) Laboratory, Emory Endosurgery Unit, Department of Surgery, Emory University School of Medicine, Atlanta, GA, United States (b) National Capitol Area Medical Simulation Center, Norman M. Rich Department of Surgery, Uniformed Services University, 4301 Jones Bridge Rd., Bethesda, MD 20814, United States (c) Center for Advanced Medical Simulation, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden Article History: Received 4 July 2005; Revised 15 March 2006

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2004.04.008 Byline: Anthony G. Gallagher (a)(b), E. Matt Ritter (a), Andrew B. Lederman (a), David A. McClusky (a), C. Daniel Smith (a) Keywords: Video-assisted surgery; Video imaging; Laparoscopy; Depth perception Abstract: Loss of depth cues is a major challenge facing surgeons performing video-assisted surgery (VAS). Whether the degradation of image quality from a video-displayed image plays a direct role in performance of VAS has not been studied. Author Affiliation: (a) Emory Endosurgery Unit, Department of Surgery, H-124, Emory University School of Medicine, 1364 Clifton Road, NE, Atlanta, GA 30322, USA (b) School of Psychology, Queens University, Belfast, Northern Ireland Article History: Received 26 September 2003; Revised 15 April 2004

Purpose: In particular after the onset of the COVID-19 pandemic, there was a precipitous rush to implement virtual and online learning strategies in surgery and medicine. It is essential to understand whether this approach is sufficient and adequate to allow the development of robotic basic surgical skills. The main aim of the authors was to verify if the quality assured eLearning is sufficient to prepare individuals to perform a basic surgical robotic task. Methods: A prospective, randomized and multi-center study was conducted in September 2020 in the ORSI Academy, International surgical robotic training center. Forty-seven participants, with no experience but a special interest in robotic surgery, were matched and randomized into four groups who underwent a didactic preparation with different formats before carrying out a robotic suturing and anastomosis task. Didactic preparation methods ranged from a complete eLearning path to peer-reviewed published manuscripts describing the suturing, knot tying and task assessment metrics. Results: The primary outcome was the percentage of trainees who demonstrated the quantitatively defined proficiency benchmark after learning to complete an assisted but unaided robotic vesico-urethral anastomosis task. The quantitatively defined benchmark was based on the objectively assessed performance (i.e., procedure steps completed, errors and critical errors) of experienced robotic surgeons for a proficiency-based progression (PBP) training course. None of the trainees in this study demonstrated the proficiency benchmarks in completing the robotic surgery task. Conclusions: PBP-based e-learning methodology is an effective training method avoiding critical errors in the suturing and knotting task. Quality assured online learning is insufficient preparation for robotic suturing and knot tying anastomosis skills. Trial registration: ClinicalTrials.gov Identifier: NCT04541615.

Background: To improve patient safety, there is an imperative to develop objective performance metrics for basic surgical skills training in robotic surgery. Objective: To develop and validate (face, content, and construct) the performance metrics for robotic suturing and knot tying, using a chicken anastomotic model. Design, setting and participants: Study 1: In a procedure characterization, we developed the performance metrics (i.e., procedure steps, errors, and critical errors) for robotic suturing and knot tying, using a chicken anastomotic model. In a modified Delphi panel of 13 experts from four EU countries, we achieved 100% consensus on the five steps, 18 errors and four critical errors (CE) of the task. Conclusions: We demonstrated face, content, and construct validity for a standard and replicable basic anastomotic robotic suturing and knot tying task on a chicken model. Patient summary: Validated, objective, and transparent performance metrics of a robotic surgical suturing and knot tying tasks are imperative for effective and quality assured surgical training.

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AimsThe purpose of this study was to (1) characterise the procedure of phlebotomy, deconstruct it into its constituent parts and develop a performance metric for the purpose of training healthcare professionals in a large teaching hospital and to (2) evaluate the construct validity of the phlebotomy metric and establish a proficiency benchmark.MethodBy engaging with a multidisciplinary team with a wide range of experience of preanalytical errors in phlebotomy and observing video recordings of the procedure performed in the actual working environment, we defined a performance metric. This was brought to a modified Delphi meeting, where consensus was reached by an expert panel. To demonstrate construct validity, we used the metric to objectively assess the performance of novices and expert practitioners.ResultsA phlebotomy metric consisting of 11 phases and 77 steps was developed. The mean inter-rater reliability was 0.91 (min 0.83, max 0.95). The expert group completed more steps of the procedure (72 vs 69), made fewer errors (19 vs 13, p=0.014) and fewer critical errors (1 Vs 4, p=0.002) than the novice group.ConclusionsThe metrics demonstrated construct validity and the proficiency benchmark was established with a minimum observation of 69 steps, with no critical errors and no more than 13 errors in total.

Reliable performance assessment is a necessary prerequisite for outcome-based assessment of surgical technical skill. Numerous observational instruments for technical skill assessment have been developed in recent years. However, methodological shortcomings of reported studies might negatively impinge on the interpretation of inter-rater reliability.

OBJECTIVE To examine the effect of previous-day excessive alcohol consumption on laparoscopic surgical performance. DESIGN Study 1 was a randomized controlled trial. Study 2 was a cohort study. SETTING Surgical skills laboratory. PARTICIPANTS Sixteen science students (laparoscopic novices) participated in study 1. Eight laparoscopic experts participated in study 2. INTERVENTIONS All participants were trained on the Minimally Invasive Surgical Trainer Virtual Reality (MIST-VR). The participants in study 1 were randomized to either abstain from alcohol or consume alcohol until intoxicated. All study 2 subjects freely consumed alcohol until intoxicated. Subjects were assessed the following day at 9 AM, 1 PM, and 4 PM on MIST-VR tasks. MAIN OUTCOME MEASURES Assessment measures included time, economy of diathermy use, and error scores. RESULTS In study 1, both groups performed similarly at baseline, but the alcohol group showed deterioration on all performance measures after alcohol consumption. Overall, although the time score differences between the 2 groups were not statistically significant (P = .29), there was a significant difference between the 2 groups' diathermy (P < .03) and error (P < .003) scores. There was also a significant effect for time of testing (P < .003), diathermy (P < .001), and errors (P < .001). In study 2, experts demonstrated a similar postalcohol performance decrement for time (P < .02), diathermy (P < .001), and error scores (P < .001). CONCLUSION Excessive consumption of alcohol appeared to degrade surgical performance the following day even at 4 PM, suggesting the need to define recommendations regarding alcohol consumption the night before assuming clinical surgical responsibilities.Arch Surg. 2011;146(4):419-426--

Training and assessment methods for knot tying by medical students or residents have traditionally been subjective. Objective methods for evaluating creation of a tied knot should include assessing the strength and quality of the knotted suture. The purpose of this study was to evaluate the use of a tensiometer as a feedback device for improving knot-tying performance. Twelve medical students with no knot-tying experience were selected to perform three-throw instrument ties with 00 silk suture. Students were randomly assigned to perform between 10 and 20 baseline knots and then received one of four feedback training conditions followed by 10 completion knots. Subjects were timed, and all knots were pulled in the tensiometer to assess for strength and slippage. Differences between baseline and completed knots for each subject were analyzed with an unpaired ttest. Subjects receiving both subjective and tensiometer feedback demonstrated the greatest improvements in knot quality score (KQS) and slip percentage (Subject 1: 0.15 ± 0.9 vs0.21 ± 0.05, P< 0.04, 75% vs60%, P= NS; Subject 2: 0.22 ± 0.10 vs0.29 ± 0.05, P< 0.02, 33% vs0%, P< 0.05; Subject 3: 0.10 ± 0.07 vs0.25 ± 0.07, P< 0.0001, 60% vs10%, P< 0.01). Objective assessment of knot-tying performance is possible using the tensiometer device. Introduction of the tensiometer during the learning phase produced improved KQS and slip percentage in most students regardless of the number of baseline knots tied. Greatest improvements in performance were seen when the tensiometer was used in combination with subjective instruction.

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21 st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.

Most patients with a terminal illness die in hospital, yet the opinions of their prime carers are largely ignored. This study investigated registered nurses’ perceptions of palliative care in district general hospitals. A random sample of 263 nurses was surveyed, using a pre-piloted questionnaire, and results showed that 70% of general ward nurses believe that managing care of the dying is an integral part of hospital care. However, their dissatisfaction with the care they give is reflected in the mere 8% who consider hospital an ideal setting for patients who are dying. Although nurses are confident in their physical/clinical role, dealing with psychosocial issues is more problematic. A minority feel confident in discussing death and dying with the patient. Barriers to optimal palliative care on general wards were perceived as lack of appropriate education and training, work pressures, and lack of support from medical colleagues and managers.

Objective assessment of psychomotor skills in surgery is now a priority; however, this assessment is difficult to achieve because of measurement difficulties associated with the reliability and validity of assessing surgical skills in vivo and in the laboratory. In this study virtual reality (VR) was used to overcome these problems in the objective psychomotor assessment of senior, junior, and novice laparoscopists. Twelve experienced laparoscopic surgeons (performed >50 Minimal Access Surgery (MAS) procedures), 12 inexperienced laparoscopic surgeons (<10 MAS procedures), and 12 laparoscopic novices (no MAS procedures) participated in the study. Each subject completed all six tasks of the Minimally Invasive Surgical Trainer; Virtual Reality (MIST VR). In comparison to the other groups, experienced laparoscopic surgeons performed the tasks significantly (p < 0.01) faster, had a lower error rate, were more economic in their movement of surgical instruments and in the use of diathermy. As a group they also showed greater consistency in their performance. MIST VR distinguished between the three groups of laparoscopists. VR provides a useful objective assessment tool for evaluating psychomotor skills for laparoscopic surgery.