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The present study aimed to assess long-term functional outcomes of children with anorectal malformations (ARMs) across a network of expert centers in France.Retrospective cross-sectional study of patients ages 6-30 years that had been surgically treated for ARM. Patient and ARM characteristics (eg, level, surgical approach) and functional outcomes were assessed in the different age groups.Among 367 patients, there were 155 females (42.2%) and 212 males (57.8%), 188 (51.2%) cases with, and 179 (48.8%) higher forms without, perineal fistula. Univariate and multivariate statistical analyses with logistic regression showed correlation between the level of the rectal blind pouch and voluntary bowel movements (odds ratio [OR] = 1.84 [1.31-2.57], P 0.001), or soiling (OR = 1.72 [1.31-2.25], P 0.001), which was also associated with the inability to discriminate between stool and gas (OR = 2.45 [1.28-4.67], P = 0.007) and the presence of constipation (OR = 2.97 [1.74-5.08], P 0.001). Risk factors for constipation were sacral abnormalities [OR = 2.26 [1.23-4.25], P = 0.01) and surgical procedures without an abdominal approach (OR = 2.98 [1.29-6.87], P = 0.01). Only the holding of voluntary bowel movements and soiling rates improved with age.This cross-sectional study confirms a strong association between anatomical status and functional outcomes in patients surgically treated for ARM. It specifically highlights the need for long-term follow-up of all patients to help them with supportive care.

Proximal hypospadias surgery is impacted by a high complication rate. The goal of this work was to assess the overall composite complication rate, fistula rate and stenosis rate following proximal hypospadias surgery realized according to onlay urethroplasty, Duckett, Koyanagi and Bracka techniques.The databases MEDLINE, EMBASE, SCOPUS, Cochrane Library, the Cochrane Database of Systematic Reviews and the Cochrane Central Register of Controlled Trials (CENTRAL) and Sciencedirect were searched. Studies had to report data about the mean age of population, the average duration of patient follow-up and the number of procedures required for surgical treatment of primary and proximal hypospadias. Two independent including one urologist reviewers screened all the articles and selected the articles to be included.Overall composite complication rates were 32%, 34%, 49%, and 43%, for Onlay urethroplasty, Duckett's tubularized flaps urethroplasty, Koyanagi repair and Bracka 2 stages repair, respectively. Fistula rates were 13%, 18%, 21% and 23% respectively. The heterogeneity of complication rates reported in the different studies was not moderated by age, country, or patient's continent origin.The classifications of complications used in articles were disparate and make comparisons between techniques difficult. The report of post-surgical complications in the literature is often poorly coded and follow-up times were often too short.This meta-analysis attempts to determine to the extent possible, given the serious weaknesses in the hypospadias literature, plausible estimates of complication rates after skin flap urethroplasty. The patched onlay skin flap, the Duckett's tubularized skin flap technique, the Koyanagi's technique, and the Bracka's two-stage urethroplasty procedure lead to very high complication rates. Reported complication rates are comparable across techniques.

When learning procedures in real life, learners generally use action atomization strategies (interleaving instructions consultation and execution) and need several repetitions to acquire the skill. However, in studies on procedural learning, delayed execution paradigms (2 separate steps consisting of instructions consultation, then execution) and/or only 1 execution of the task, are commonly used methods. The aim of the present study was to examine the effects of those two paradigms on procedural learning. The effects of the procedure repetition were also studied. Forty-two undergraduate medical students were asked to make 5 stitches, either in an atomized or a delayed manner. The hypothesis was that participants who had learned in an atomized manner would perform better than those who had learned in a delayed manner, because the former approach may have helped them reduce task-related cognitive load. Results show an effect of repetition of the procedure on participants’ performance, and confirm the need to examine more than one execution of a procedure when studying procedural learning. Moreover, different outcomes in terms of suture quality and speed of instructions consultation were observed for the two learning paradigms. This implies that studying learning following a delayed execution paradigm may lead to distorted results compared to procedural learning occurring in real-life situations. (PsycINFO Database Record (c) 2019 APA, all rights reserved)

The clinical process for the diagnosis of intra-abdominal lesion due to blunt abdominal trauma in children is not consistent. The goal of the present study was to assess the efficiency of our institutional procedure to manage hemodynamically stable pediatric patients with benign abdominal trauma and to select patients who need a radiological examination in an emergency pediatric department. This was a prospective cohort study from June 2008 to June 2010 in a pediatric emergency department. Pediatric patients with benign abdominal trauma and with stable hemodynamic parameters were included in the study. We conducted first clinical examination and clinical laboratory assessment for blood count, platelet count, hematocrit, serum glutamo-oxalacetique transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT), lipase and urine. A second clinical examination was performed 2 h later. Patients with biological abnormalities and/or with persistent pain underwent a computerized tomography (CT) of the abdomen. Our main criterion for judging was the presence of intra-abdominal lesion as revealed by the scan, which was considered as the gold standard. At the second clinical examination, patients without pain and with normal results for clinical laboratory assessment were sent home. A telephone call was made to the children 48 h after the visit to the hospital emergency department. The secondary criterion for judging was the absence of complication in children who did not undergo the scan. A total of 111 children were included. Seventy-five children underwent the complete procedure. Thirty-four scans were performed. The scan revealed that 22 patients had an intra-abdominal lesion. Multivariate analysis indicated that SGOT higher than 34 IU/L and the persistence of pain for more than 2 h from the initial evaluation of trauma favored the development of intra-abdominal lesion. On the basis of these two criteria, we developed a predictive diagnostic score for post-traumatic intra-abdominal injuries with a high negative predictive value. For children who were sent home without a radiological examination, no complications were observed at 48 h after the visit to the emergency department. The present protocol is a good approach to identify children at risk for intra-abdominal lesion who need a radiological examination and those who do not require any complementary examinations. The predictive diagnostic score could help young hospital doctors to assess blunt abdominal trauma.

BACKGROUND AND OBJECTIVES Respiratory diseases are common in children with esophageal atresia (EA), leading to increased morbidity and mortality in the first year. The primary study objective was to identify the factors associated with readmissions for respiratory causes in the first year in EA children. METHODS A population-based study. We included all children born between 2008 and 2016 with available data and analyzed factors at birth and 1 year follow-up. Factors with a P value RESULTS Among 1460 patients born with EA, 97 (7%) were deceased before the age of 1 year, and follow-up data were available for 1287 patients, who constituted our study population. EAs were Ladd classification type III or IV in 89%, preterm birth was observed in 38%, and associated malformations were observed in 52%. Collectively, 61% were readmitted after initial discharge in the first year, 31% for a respiratory cause. Among these, respiratory infections occurred in 64%, and 35% received a respiratory treatment. In logistic regression models, factors associated with readmission for a respiratory cause were recurrence of tracheoesophageal fistula, aortopexy, antireflux surgery, and tube feeding; factors associated with respiratory treatment were male sex and laryngeal cleft. CONCLUSIONS Respiratory morbidity in the first year after EA repair is frequent, accounting for >50% of readmissions. Identifying high risk groups of EA patients (ie, those with chronic aspiration, anomalies of the respiratory tract, and need for tube feeding) may guide follow-up strategies.

In Hirschsprung’s disease (HSCR), postoperative course remains unpredictable. Our aim was to define predictive factors of the main postoperative complications: obstructive symptoms (OS) and Hirschsprung-associated enterocolitis (HAEC). In this prospective multicentre cohort study, samples of resected bowel were collected at time of surgery in 18 neonates with short-segment HSCR in tertiary care hospitals. OS and HAEC were noted during postoperative follow-up. We assessed the enteric nervous system and the intestinal epithelial barrier (IEB) in ganglionic segments by combining immunohistochemical, proteomic and transcriptomic approaches, with functional ex vivo analysis of motility and para/transcellular permeability. Ten HSCR patients presented postoperative complications (median follow-up 23.5 months): 6 OS, 4 HAEC (2 with OS), 2 diarrhoea (without OS/HAEC). Immunohistochemical analysis showed a significant 41% and 60% decrease in median number of nNOS-IR myenteric neurons per ganglion in HSCR with OS as compared to HSCR with HAEC/diarrhoea (without OS) and HSCR without complications (p = 0.0095; p = 0.002, respectively). Paracellular and transcellular permeability was significantly increased in HSCR with HAEC as compared to HSCR with OS/diarrhoea without HAEC (p = 0.016; p = 0.009) and HSCR without complications (p = 0.029; p = 0.017). This pilot study supports the hypothesis that modulating neuronal phenotype and enhancing IEB permeability may treat or prevent postoperative complications in HSCR.

OBJECTIVE: To identify the risk factors for early mortality and morbidity in a population with distal esophageal atresia (EA)-tracheoesophageal fistula. STUDY DESIGN: Cohort study from a national register. Main outcomes and measures included early mortality, hospital length of stay (LoS), need for nutritional support at 1 year of age as a proxy measure of morbidity, and complications during the first year of life. RESULTS: In total, 1008 patients with a lower esophageal fistula were included from January 1, 2008, to December 31, 2014. The survival rate at 3 months was 94.9%. The cumulative hospital LoS was 31.0 (17.0-64.0) days. Multivariate analysis showed that intrahospital mortality at 3 months was associated with low birth weight (OR 0.52, 95% CI [0.38-0.72], P

Purpose Surgical simulation has benefited from a surge in interest over the last decade because of the increasing need for a change in the traditional apprenticeship model of teaching surgery. Open surgery for ureteropelvic junction (UPJ) poses unique training challenges owing to smaller workspaces, and finer sutures used that require increased surgical dexterity when compared with adult analogues. We describe the development and face validation of a low-cost training simulator for open dismembered pyeloplasty. Materials and methods The simulator is built with A4 Kraft envelopes, catheter tip syringe filled with 30 mL of air, tape, 260 modeling balloon, and 11-in party balloon. Evaluation of the device is based on an evaluation form including 11 items on a 5-point Likert-type scale. Thirty-one departments of pediatric surgery in France were contacted and received a pack containing 4 to 10 devices, already set up and ready for use, a tutorial and an evaluation form. Candidates were stratified according to their level of expertise. Results A total of 180 devices were sent. Procedures on the device were performed 118 times (65%) by expert surgeons ( n = 44), fellows ( n = 25), and residents ( n = 49). Statistically significant difference was noted for 4 items (anatomy, model exposition, UPJ resection, and difficulty) for the 3 levels of expertise. The global score evaluation for realistic items, face validity, and usability was 4.2 (range: 1-5). Conclusion This low-cost model is evaluated as an efficient tool for UPJ teaching and training. It shows promise as an educational tool.

Background Verbal and non-verbal communication, as well as empathy are central to patient-doctor interactions and have been associated with patients’ satisfaction. Non-verbal communication tends to override verbal messages. The aim of this study was to analyze how medical students use verbal and non-verbal communication using two different educational approaches, student role play (SRP) and actor simulated patient (ASP), and whether the non-verbal behaviour is different in the two different poses. Methods Three raters evaluated 20 students playing the doctor role, 10 in the SRP group and 10 in the ASP group. The videos were analyzed with the Calgary-Cambridge Referenced Observation Guide (CCG) and, for a more accurate evaluation of non-verbal communication, we also evaluated signs of nervousness, and posture. Empathy was rated with the CARE questionnaire. Independent Mann Whitney U tests and Qhi square tests were performed for statistical analysis. Results From the 6 main tasks of the CCG score, we obtained higher scores in the ASP group for the task ‘Gathering information’ (p = 0.0008). Concerning the 17 descriptors of the CCG, the ASP group obtained significantly better scores for ‘Exploration of the patients’ problems to discover the biomedical perspective’ (p = 0.007), ‘Exploration of the patients’ problems to discover background information and context’ (p = 0.0004) and for ‘Closing the session – Forward planning’ (p = 0.02). With respect to non-verbal behaviour items, nervousness was significantly higher in the ASP group compared to the SRP group (p Conclusions Medical students displayed differentiated verbal and non-verbal communication behaviour during the two communication skills training methodologies. These results show that both methodologies have certain advantages and that more explicit non-verbal communication training might be necessary in order to raise students’ awareness for this type of communication and increase doctor-patient interaction effectiveness.

International audience; Objective: To identify predictors of and factors associated with the performance of antireflux surgery during the first year of life in children born with esophageal atresia.Study design: All patients were included in a French registry for esophageal atresia. All 38 multidisciplinary French centers completed questionnaires about perinatal characteristics and one-year outcome for children born with esophageal atresia.Results: Of 835 infants with esophageal atresia born in France from 2010 to 2014, 682 patients, excluding those with long-gap esophageal atresia, were included. Three patients had type I, 669 had type III, and 10 had type IV esophageal atresia. Fifty-three children (7.8%) received fundoplication during the first year of life. The median age at the time of the end-to-end esophageal anastomosis was 1.1 day (range 0-15). Multivariate analysis identified three perioperative factors that predicted the need for early antireflux surgery: anastomotic tension (P = .004), associated malformations (P = .019), and low birth weight (P = .018). Six other factors, measured during the first year of life, were associated with the need for antireflux surgery: gastroesophageal reflux (P < .001), anastomotic stricture (P < .001), gastrostomy (P < .001), acute life-threatening event (P = .002), respiratory complications (P = .045), and poor nutritional status (P < .001).Conclusions: Gastroesophageal reflux disease, low birth weight, poor nutrition, and surgical anastomosis difficulties predicted the performance of antireflux surgery in the first year of life in infants with esophageal atresia.

Objective To evaluate prenatal ultrasound parameters as prognostic factors for complex and vanishing gastroschisis. Methods Retrospective multicentre study of 200 gastroschisis over 13 years (2000–2013). Collection of prenatal ultrasound evaluation on maternal and fetal growth parameters, intra- and extra-abdominal bowel and stomach dilation, abdominal wall defect diameter and changes in bowel appearance. Correlation of these factors with the presence of mechanical intestinal complications at birth, named ‘complex gastroschisis’. Results Fifty-two patients (26%) had complex gastroschisis (CG), including ten vanishing gastroschisis. The presence of intra-abdominal bowel dilation at the second (T2) or third (T3) trimester ultrasound was predictive for CG, with odds ratios at 6.69 (95%CI 2.41–18.55) and 4.72 (95%CI 2.16–10.28), respectively, with a cut-off value at the last examination of >19 mm. A small abdominal wall defect diameter was also predictive for CG, with cut-off values of

International audience; INTRODUCTION: Thoracotomy as surgical approach for esophageal atresia treatment entails the risk of deformation of the rib cage and consequently secondary thoracogenic scoliosis. The aim of our study was to assess these thoracic wall anomalies on a large national cohort and search for factors influencing this morbidity.MATERIALS AND METHODS: Pediatric surgery departments from our national network were asked to send recent thoracic X-ray and operative reports for patients born between 2008 and 2010 with esophageal atresia. The X-rays were read in a double-blind manner to detect costal and vertebral anomalies.RESULTS: Among 322 inclusions from 32 centers, 110 (34.2%) X-rays were normal and 25 (7.7%) displayed thoracic malformations, including 14 hemivertebrae. We found 187 (58.1%) sequelae of surgery, including 85 costal hypoplasia, 47 other types of costal anomalies, 46 intercostal space anomalies, 21 costal fusions and 12 scoliosis, with some patients suffering from several lesions. The rate of patients with these sequelae was not influenced by age at intervention, weight at birth, type of atresia, number of thoracotomy or size of the center. The rate of sequelae was higher following a classical thoracotomy (59.1%), whatever the way that thoracotomy was performed, compared to nonconverted thoracoscopy (22.2%; p=0.04).CONCLUSION: About 60 % of the patients suffered from a thoracic wall morbidity caused by the thoracotomy performed as part of surgical treatment of esophageal atresia. Minimally invasive techniques reduced thoracic wall morbidity. Further studies should be carried out to assess the potential benefit of minimally invasive approaches to patient pulmonary functions and on the occurrence of thoracogenic scoliosis in adulthood.LEVELS OF EVIDENCE: Level III retrospective comparative treatment study.

To evaluate prenatal ultrasound parameters as prognostic factors for complex and vanishing gastroschisis.Retrospective multicentre study of 200 gastroschisis over 13 years (2000-2013). Collection of prenatal ultrasound evaluation on maternal and fetal growth parameters, intra- and extra-abdominal bowel and stomach dilation, abdominal wall defect diameter and changes in bowel appearance. Correlation of these factors with the presence of mechanical intestinal complications at birth, named 'complex gastroschisis'.Fifty-two patients (26%) had complex gastroschisis (CG), including ten vanishing gastroschisis. The presence of intra-abdominal bowel dilation at the second (T2) or third (T3) trimester ultrasound was predictive for CG, with odds ratios at 6.69 (95%CI 2.41-18.55) and 4.72 (95%CI 2.16-10.28), respectively, with a cut-off value at the last examination of19 mm. A small abdominal wall defect diameter was also predictive for CG, with cut-off values of9.2 mm at T2 and12.5 mm at T3. Vanishing gastroschisis recorded earlier intra-abdominal bowel dilation diagnosis, associated with a small wall defect and no extra-abdominal dilation.Intra-abdominal bowel dilation and a small abdominal wall defect diameter accurately predict CG and could be a first sign of vanishing gastroschisis when they occur early. © 2016 John WileySons, Ltd.

International audience; In faculties of medicine today, a growing number of medical procedures are taught in manual techniquesworkshops. These workshops leave the students only very little time to train. One solution to thisproblem would be to provide medical students with an opportunity to practice these skills by themselvesthanks to online learning materials. In order to determine the instruction presentation medium bestsuited to complete this training, different formats were compared (video + audio, video þtext, andphotographs + text). Forty-eight students were required to do five sutures using one of these formats.Their performance was assessed by time measurements and measurements of the quality of the knots.For all of the time indicators, the results show that the videos were more effective than the photographsfor the first trial. This trend was reversed for the following trials, where the performance levels recordedusing the photographs were better than those using the videos. The quality of the knots, however, wassystematically better with the photographs than with the videos for all of the trials.

The case of a 4-year-old boy in whom a pedicled second metatarsal flap was used for lateral malleolar reconstruction after lawnmower injury is presented. Leg initial assessment demonstrated a 5cm bone loss at the distal fibula combined with severe soft tissue damage. Immediate healing was achieved with split-thickness skin graft but secondary reconstruction was necessary to obtain bone replacement with soft tissue coverage to allow bone growth and shoe donning. To avoid microsurgical fibular epiphyseal transplant morbidity and complications, we used a pedicled second metatarsal flap based on the dorsalis pedis vessels including the second metatarsal bone, the skin of the second toe and the brevis pedis muscle. Repair of the donor side was performed with direct suture and no post-operative course complication was noted. At seven-year follow-up, transferred bone had excellent growth and the patient had adequate ankle function and stable ride. The case provides technique descriptions, considerations in the paediatric population, an overview of other techniques and a seven-year follow-up. It suggests that vascularized chimeric second metatarsal flap may be a useful option in paediatric distal fibula reconstruction.

Background The aim of the present national prospective population-based study was to assess the early morbidity of esophageal atresia (EA). Methods All 38 multidisciplinary French centers that care for patients with EA returned a specific questionnaire about the 1-year outcome for each patient. This information was centralized, checked, and entered into a database. Results From the total population of 307 EA patients born in 2008 and 2009, data about the 1-year outcome were obtained from 301 (98%) patients, of whom 4% were lost to follow-up and 5% died. Medical complications occurred in 34% of the patients: anastomotic leaks (8%), recurrent tracheoesophageal fistula (4%), and anastomotic stenosis (22%); all of the latter group needed dilation (median, 2 dilations/patient). A new hospitalization was required for 59% of patients (2.5 hospitalizations/patient) for digestive (52%) or respiratory (48%) reasons. Twelve percent of patients required antireflux surgery at a median age of 164 days (range, 33–398 days), and 1% underwent an aortopexy for severe tracheomalacia. The weight/age Z-score was −0.8 (range, −5.5 to 3.7 months) at 12 months. Fifteen percent of patients were undernourished at 12 months of age, whereas 37% presented with respiratory symptoms and 15% had dysphagia at the last follow-up. Significant independent factors associated with medical complications were anastomotic esophageal tension (p = .0009) and presence of a gastrostomy (p = .0002); exclusive oral feeding at discharge was associated with a decreased risk of complications (p = .007). Conclusions Digestive and respiratory morbidities remain frequent during the first year of life and are associated with difficult anastomosis and lack of full oral feeding. Electronic supplementary material The online version of this article (doi:10.1186/s13023-014-0206-5) contains supplementary material, which is available to authorized users.

Postnatal changes in the enteric nervous system (ENS) are involved in the establishment of colonic motility. In adult rats, butyrate induced neuroplastic changes in the ENS, leading to enhanced colonic motility. Whether butyrate can induce similar changes during the postnatal period remains unknown. Enemas (Na-butyrate) were performed daily in rat pups between postnatal day (PND) 7 and PND 17. Effects of butyrate were evaluated on morphological and histological parameters in the distal colon at PND 21. The neurochemical phenotype of colonic submucosal and myenteric neurons was analyzed using antibodies against Hu, choline acetyltransferase (ChAT), and neuronal nitric oxide synthase (nNOS). Colonic motility and neuromuscular transmission was assessed in vivo and ex vivo. Butyrate (2.5 mM) enemas had no impact on pup growth and histological parameters compared with control. Butyrate did not modify the number of Hu-immunoreactive (IR) neurons per ganglia. A significant increase in the proportion (per Hu-IR neurons) of nNOS-IR myenteric and submucosal neurons and ChAT-IR myenteric neurons was observed in the distal colon after butyrate enemas compared with control. In addition, butyrate induced a significant increase in both nitrergic and cholinergic components of the neuromuscular transmission compared with control. Finally, butyrate increased distal colonic transit time compared with control. We concluded that butyrate enemas induced neuroplastic changes in myenteric and submucosal neurons, leading to changes in gastrointestinal functions. Our results support exploration of butyrate as potential therapy for motility disorders in preterm infants with delayed maturation of the ENS.

The objective of this retrospective study was to assess the value of one-stage testicular descent without spermatic vessel ligation for intraabdominal impalpable testis.This study was based on 90 children with 98 impalpable testes. Laparoscopic exploration was performed in each case. Forty-three testes were intra-abdominal and 55 were absent. One-stage surgical descent with vertical opening of the conjoined tendon and without spermatic vessel ligation was performed for 22 testes and two-stage descent (Fowler-Stephens two-stage technique) was performed for 16 testes. Three testes in bilateral forms are still waiting for treatment.With a mean follow-up of 17 months (range: 1 month to 8 years), 18 of the 22 testes (81%) were situated in the scrotum and were viable in the one-stage treatment group, versus 10 out of 16 (62.5%) in the two-stage group. Two poor results, including one case of necrosis, were observed after one-stage testicular descent. Six poor results, including two cases of necrosis, were observed after the Fowler-Stephens two-stage technique.One-stage testicular descent, without spermatic vessel ligation, after laparoscopic assessment of the presence and position of the testis, can be performed in the majority of cases of impalpable testis. The risks of failure due to secondary atrophy or incomplete testicular descent are minimal with this technique. One-stage surgical descent, when possible, appears to be preferable to the Fowler-Stephens two-stage procedure.

Learning surgical gestures is an important part of training for medical profession. An ethical imperative now requires that these gestures must be learned in a simulation situation. The objective of this thesis was to determine the psychological and pedagogical factors for optimizing procedural learning among medical students by combining e-learning and simulation. To meet this objective, we have implemented 5 studies. The first study sought to confirm that learners did realize an action atomization process at the beginning of learning. The second study compared the use of a methodological paradigm allowing action atomization and a paradigm of delayed execution. The next two studies were concerned with the instructions design and more particularly with their perspective, taking into account the visuospatial abilities of the learners.The last study investigated the validity of a blended learning course by comparing two educational organizations. The contributions of this thesis fall into 3 areas. In terms of the procedural learning process, the learners atomize the action during the first phase of procedural learning. Methodologically, it is therefore essential that the study paradigm takes into account this process, as well as the many repetitions necessary for procedural learning. From an educational point of view, the self-centered point of view would be the most profitable, whatever the visuo-spatial abilities of the learners. Finally, using a combination of e-learning and face-to-face simulation seems to be effective for procedural learning.; L’apprentissage de gestes chirurgicaux, est un élément majeur de la formation des professions médicales. Un impératif éthique impose désormais que l’apprentissage de ces gestes s’effectue en simulation. Le but de cette thèse était de déterminer les facteurs psychologiques et pédagogiques permettant d’optimiser l’apprentissage procédural chez des étudiants en Médecine en combinant e-learning et simulation. Pour répondre à cet objectif nous avons mis en place 5 études. La première cherchait à vérifier que les apprenants réalisaient une atomisation de l’action en début d’apprentissage. La deuxième comparait l’utilisation d’un paradigme permettant l’atomisation de l’action et d’un paradigme de réalisation différée. Les deux études suivantes s’intéressaient à l’ergonomie des instructions et plus particulièrement au point de vue de présentation, en tenant compte des aptitudes visuo-spatiales des apprenants. La dernière étude visait à vérifier la validité d’une situation d’apprentissage en blended learning, en comparant deux organisations pédagogiques. Les apports de cette thèse se situent à 3 niveaux. Au plan du déroulement de l'apprentissage procédural, les apprenants réalisent une atomisation de l’action lors de la première phase de l’apprentissage. Au plan méthodologique, il est donc essentiel que le paradigme d’étude utilisé prenne en compte ce processus, ainsi que les nombreuses répétitions nécessaires à l’apprentissage procédural. Au plan pédagogique, le point de vue égocentré serait le plus profitable, quelles que soient les aptitudes des apprenants. Enfin, l’utilisation d’une combinaison de e-learning et de simulation semble efficace pour l’apprentissage de procédures.

Learning surgical gestures is an important part of training for medical profession. An ethical imperative now requires that these gestures must be learned in a simulation situation. The objective of this thesis was to determine the psychological and pedagogical factors for optimizing procedural learning among medical students by combining e-learning and simulation. To meet this objective, we have implemented 5 studies. The first study sought to confirm that learners did realize an action atomization process at the beginning of learning. The second study compared the use of a methodological paradigm allowing action atomization and a paradigm of delayed execution. The next two studies were concerned with the instructions design and more particularly with their perspective, taking into account the visuospatial abilities of the learners.The last study investigated the validity of a blended learning course by comparing two educational organizations. The contributions of this thesis fall into 3 areas. In terms of the procedural learning process, the learners atomize the action during the first phase of procedural learning. Methodologically, it is therefore essential that the study paradigm takes into account this process, as well as the many repetitions necessary for procedural learning. From an educational point of view, the self-centered point of view would be the most profitable, whatever the visuo-spatial abilities of the learners. Finally, using a combination of e-learning and face-to-face simulation seems to be effective for procedural learning.; L’apprentissage de gestes chirurgicaux, est un élément majeur de la formation des professions médicales. Un impératif éthique impose désormais que l’apprentissage de ces gestes s’effectue en simulation. Le but de cette thèse était de déterminer les facteurs psychologiques et pédagogiques permettant d’optimiser l’apprentissage procédural chez des étudiants en Médecine en combinant e-learning et simulation. Pour répondre à cet objectif nous avons mis en place 5 études. La première cherchait à vérifier que les apprenants réalisaient une atomisation de l’action en début d’apprentissage. La deuxième comparait l’utilisation d’un paradigme permettant l’atomisation de l’action et d’un paradigme de réalisation différée. Les deux études suivantes s’intéressaient à l’ergonomie des instructions et plus particulièrement au point de vue de présentation, en tenant compte des aptitudes visuo-spatiales des apprenants. La dernière étude visait à vérifier la validité d’une situation d’apprentissage en blended learning, en comparant deux organisations pédagogiques. Les apports de cette thèse se situent à 3 niveaux. Au plan du déroulement de l'apprentissage procédural, les apprenants réalisent une atomisation de l’action lors de la première phase de l’apprentissage. Au plan méthodologique, il est donc essentiel que le paradigme d’étude utilisé prenne en compte ce processus, ainsi que les nombreuses répétitions nécessaires à l’apprentissage procédural. Au plan pédagogique, le point de vue égocentré serait le plus profitable, quelles que soient les aptitudes des apprenants. Enfin, l’utilisation d’une combinaison de e-learning et de simulation semble efficace pour l’apprentissage de procédures.