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Objective: To document the utilization and training of laparoscopic and thoracoscopic minimally invasive surgery (MIS) techniques within the American, European, Australian and New Zealand Colleges of Small Animal Veterinary Surgeons (ACVS, ECVS, and ANZCVS) in 2020., Study Design: Observational study., Sample Population: Diplomates and residents of the ACVS, ECVS, and FANZCVS., Methods: An electronic survey was sent using veterinary list servers. Questions were organized into categories evaluating (1) the demographics of the study population and the caseload, (2) comfort level with specific procedures, (3) motivating factors and limitations, and (4) surgical training and the role of the governing bodies., Results: Respondents included 111 practicing surgeons and 28 residents. Respondents' soft-tissue MIS caseloads had increased since they first started performing MIS; however, most respondents were only comfortable performing basic laparoscopy. Over half of the respondents agreed on the patient benefits and high standard of care provided by MIS. Perceived adequate soft-tissue training in MIS during residency was strongly associated with perceived proficiency at the time of survey response. Most respondents agreed that the specialty colleges should take a more active role in developing standards for soft-tissue MIS, with residents agreeing that a required standardized course would be beneficial., Conclusion: Soft-tissue MIS is widely performed by diplomates and residents. Perceived adequate soft-tissue MIS training was strongly associated with perceived proficiency., Clinical Significance: There is substantial underutilization of advanced MIS techniques in veterinary specialty surgical practice, which might be improved by a stronger focus on MIS training during residency., (© 2024 American College of Veterinary Surgeons.)

Background: We designed a new Esophageal Magnetic Anastomosis Device (EMAD) for thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) without the need of handheld suturing or additional gastrostomy., Methods: Synthetic EA-TEF model: Spherical and tubular shaped rubber balloons and a term infant sized plastic doll were used. Medical students (n = 10) and surgical trainees (n = 10) were asked to perform thoracoscopic repair of an "EA" with a hand sutured anastomosis (HA) and with the EMAD. Euthanized animal model: The esophagus in 5 piglets (3-4 kg) was dissected and a thoracoscopic esophageal magnetic anastomosis (EMA) was performed. Bursting pressure (BP) and pulling force (PF): HA and EMA were created on ex vivo New Zealand white rabbit (2.5-3 kg) esophagi (n = 25 in each test series). BP and PF were measured and compared against each other., Results: Medical students were unable to complete HA, but were successful with the EMAD in 11.1 ± 2.78 min. Surgical trainees completed EMA in 4.6 ± 2.06 min vs. HA 30.8 ± 4.29 min (p<0.001). The BP following a HA (14.1 ± 3.32 cmH 2 O) was close to the physiological intraluminal pressure reported in a neonatal esophagus (around 20 cmH 2 O), whereas the BP with the EMAD was extremely high (>90 cmH 2 O) (p<0.001). The PF of an EMA (1.8 ± 0.30 N) was closer to the safety limits of anastomotic tension reported in the literature (i.e. 0.75 N) compared with the HA (3.6 ± 0.43 N) (p<0.0001)., Conclusion: The EMAD could simplify, shorten, and potentially improve the outcome of thoracoscopic repair for EA with TEF in the future. A high BS and a relative low PF following EMAD application may lower the risk of postoperative complications such as esophageal leakage and stricture formation., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: Acquiring the technical skills required for thoracoscopic repair of esophageal atresia with tracheo-esophageal fistula (EA/TEF) is challenging. A high-fidelity 3D-printed pediatric thoracoscopic EA/TEF simulator has been developed to address this issue. This study explored motion-tracking as an assessment tool to distinguish between surgeons of different expertise using the simulator., Methods: Participants performed a single intracorporeal suture between the esophageal ends in EA with TEF. Total relative path lengths of the right and left surgical instruments were recorded during the task. Each video-recorded attempt was assessed by a blinded pediatric surgeon using a modified Objective Structured Assessment of Technical Skills (OSATS) score. Data recorded as median (range) and statistical significance as p<0.05., Results: The task was performed by 17 participants. The median OSATS scores identified a significant difference between experts and novices. A difference between left- and right-hands was only found in the mid-skill level group. Right-hand path length was greatest in novices and lowest in experts. Left-hand path length was greatest in novices and the mid-skill level group compared to experts., Conclusion: Experts had the lowest total path length for either hand, suggesting they had the greatest efficiency of movement. The similar high path lengths in both hands for novices indicate their relatively low level of skill with either hand. The difference between right- and left-hand path lengths in the mid-skill level group likely reflects the improved right-handed technical skills in contrast to the still developing left hand. Further focus on the left hand during simulation training may improve left-handed economy of movement., Competing Interests: Declarations of Interests Authors Jonathan Wells and Spencer Beasley are directors of Symulus Limited which designed the simulator., (Copyright © 2022. Published by Elsevier Inc.)

Objectives: At least partially technically related, a cervical esophagogastric anastomosis has a 12% to 14% leak rate, which is theoretically reducible with simulator practice. Preliminary development and testing of a cervical esophagogastric anastomosis simulator are described., Methods: A portable, low-cost, scale reproduction of the cervical esophagogastric anastomosis operative site was engineered around a 19 × 11 × 6-cm plastic box. Silicone "esophageal" and "gastric tip" castings permitted construction of a stapled side-to-side cervical esophagogastric anastomosis guided by an illustrated curriculum. In a 2-phase pilot study, the simulator and curriculum were evaluated. Phase 1: Seven faculty evaluated fidelity using a 5-point, 24-item survey of (1) physical attributes, (2) realism of materials, (3) realism of experience, (4) value, and (5) relevance, and (6) ability to perform tasks. Overall impression of the simulator was also measured. Phase 2: Eight thoracic surgical trainees similarly evaluated the simulator and the quality of the curriculum. Faculty and trainee ratings were compared using a Rasch model, and inter-rater agreement was estimated., Results: There were no overall fidelity differences across faculty and resident ratings. Combined observed averages ranged from 4.52 (Realism of Materials) to 5.00 (Relevance). Lifelike feel of esophagus had the lowest ratings (observed average = 4.40). Residents rated interrupted outer layer of anterior closure to be more difficult (observed average = 4.13) than faculty (observed average = 4.86; P = .016, d = 1.99). Global ratings (observed average = 3.33/4.00) indicated participants believed the simulator could be used for cervical esophagogastric anastomosis training now, but could be improved slightly., Conclusions: Preliminary evidence suggests the novel cervical esophagogastric anastomosis simulator is valuable as a surgical training tool., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Thoracoscopic sleeve lobectomy is challenging, considering the technical difficulty in controlling the needle angle and thread through the port. However, effective simulation of the procedure remains to be established. Here, we describe our first experience with thoracoscopic sleeve lobectomy simulation using a three-dimensional printed thoracic model and a handmade rolled sponge. Owing to the transparent structure, we could simultaneously confirm the suturing technique through the monitor (two-dimensional) and direct vision (three-dimensional). We are certain that our realistic and easily repeatable simulation will assist in developing better technique and conduct feasible thoracoscopic sleeve lobectomy., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The thoracoscopic repair of esophageal atresia with tracheoesophageal fistula is a complex neonatal minimally invasive procedure. The thoracoscopic approach is now nearing its third decade of experience and but is overall still not widely utilized, only in skilled centers and by experienced surgeons. This article will summarize the recent advancements in technique and knowledge in the thoracoscopic approach to this challenging neonatal congenital abnormality., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Operative repair of complex conditions such as esophageal atresia and tracheoesophageal fistula (EA/TEF) is technically demanding, but few training opportunities exist outside the operating theater for surgeons to attain these skills. Learning them during surgery on actual neonates where the stakes are high, margins for error narrow, and where outcomes are influenced by technical expertise, is problematic. There is an increasing demand for high-fidelity simulation that can objectively measure performance. We developed such a simulator to measure force and motion reliably, allowing quantitative feedback of technical skill. A 3D-printed simulator for thoracoscopic repair of EA/TEF was instrumented with motion and force tracking components. A 3D mouse, inertial measurement unit (IMU), and optical sensor that captured force and motion data in four degrees of freedom (DOF) were calibrated and verified for accuracy. The 3D mouse had low average relative errors of 2.81%, 3.15%, and 6.15% for 0 mm, 10 mm offset in Y, and 10 mm offset in X, respectively. This increased to - 23.5% at an offset of 42 mm. The optical sensors and IMU displayed high precision and accuracy with low SDs and average relative errors, respectively. These parameters can be a useful measurement of performance for thoracoscopic EA/TEF simulation prior to surgery. Graphical abstract Inclusion of sensors into a high-fidelity simulator design can produce quantitative feedback which can be used to objectively asses performance of a technically difficult procedure. As a result, more surgical training can be done prior to operating on actual patients in the operating theater.

Background/purpose: Pediatric surgical trainees have limited exposure to advanced minimally invasive surgery (MIS) during their clinical training, particularly for cases such as esophageal atresia/tracheoesophageal fistula (EA/TEF). Simulation on validated neonatal models offers an alternative means of training that may augment traditional forms of training; but to be useful, they must fulfill certain criteria., Methodology: Review of the currently available MIS, thoracoscopic and laparoscopic, simulators for pediatric surgery, and identification of those factors that contribute to their fidelity and validity as a training tool that must be incorporated in the design of future simulation models., Results: There are few neonatal laparoscopic and thoracoscopic models currently available, or in the research stage. To our knowledge, there is no commercially available, synthetic, high fidelity and low cost thoracoscopic model in existence. Use of animal tissue has disadvantages of ethical dilemmas, cost, and logistic and procurement issues. Newer synthetic models need to be validated for fidelity, to replicate those components of the operation that pose the greatest technical challenge, and incorporate means of measuring acquisition of technical expertise., Conclusion: This review describes the principles that need to be considered to develop low cost, validated high-fidelity MIS simulator that can be used for training, and that is capable of measuring the acquisition of the technical skills that can be applied to the repair of complex procedures such as esophageal atresia. Level of evidence III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Diseases of the pleura and pleural space are common and present a significant contribution to the workload of respiratory physicians, with most cases resulting from congestive heart failure, pneumonia, and cancer. Although the radiographic and ultrasonographic detection of pleural abnormalities may be obvious, the determination of a specific diagnosis can often represent a challenge. Invasive procedures such as pleural drainage, ultrasound/CT-guided pleural biopsy or medical thoracoscopy can be useful in determining specific diagnosis of pleural diseases. Management of primary and secondary spontaneous pneumothorax is mandatory in an interventional pulmonology training program, while the medical or surgical treatment of the recurrence is still a matter of discussion. Pleural drainage is a diagnostic and therapeutic procedure used in the treatment of pneumothorax and pleural effusions of different etiologies and even in palliation of symptomatic in malignant pleural effusion. Medical thoracoscopy (MT) is a minimally invasive procedure aimed at inspecting the pleural space. It could be a diagnostic procedure in pleural effusions (suspected malignant pleural effusion, infective pleural disease such as empyema or tuberculosis) or therapeutic procedure (chemical pleurodesis or opening of loculation in empyema). Diagnostic yield is 95% in patients with pleural malignancies and higher in pleural tuberculosis. In parapneumonic complex effusion, MT obviates the need for surgery in most cases. Thoracoscopy training should be considered being as important as bronchoscopy training for interventional pulmonology, although prior acquisition of ultrasonography and chest tube insertion skills is essential.

Totally minimally invasive Ivor-Lewis esophagectomy (Ivor Lewis TMIE) is a technically challenging procedure and is associated with a learning curve. Refinement of surgical technique is an important part of this learning curve. However, detailed descriptions of these refinements according to the idea, development, exploration, assessment, and long-term follow-up (IDEAL) framework are lacking and this study was undertaken to fill this knowledge gap. From 2010 until 2016, all consecutive patients (n = 164) were included from the first patient undergoing Ivor Lewis TMIE. Surgical reports were analyzed and surgeons were interviewed to determine surgical refinements. These data were used to describe the transition of the surgical technique from IDEAL stage IIB to stage III. The main findings were that four refinements were made to the surgical procedure in IDEAL stage IIB: (1) At case 9, the use of the 25 mm OrVil was abandoned, exchanged for a 28 mm EEA stapler and a large omental wrap around the anastomosis was introduced; (2) at case 27, the omental wrap was reduced in volume; (3) at case 60, the omental wrap was refined to cover the full 360° of the anastomosis and (4) at case 77, the fixation of the anvil with the Endostitch was replaced by fixation with two Endoloops®. During the transition from IDEAL stage IIB to stage III, the incidence of anastomotic leakage decreased from 26.0% to 4.6% (P < 0.001) and the incidence of textbook outcome increased from 31.2% to 47.1% (P = 0.039). In conclusion, this study describes the surgical refinements that were made during the progression of Ivor Lewis TMIE from IDEAL stage IIB to IDEAL stage III. During IDEAL stage IIB, postoperative outcome improved as surgical proficiency was gained and the technique was refined., (© The Author(s) 2018. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

Objective: We aimed to develop and validate a low cost, do-it-yourself model for neonatal thoracoscopic congenital diaphragmatic hernia (CDH)., Design: Volunteers with varying skills in neonatal minimally invasive surgery tested and evaluated the model simulating a neonatal thoracoscopic CDH repair. The model was built from ordinary materials purchased in a dime store: a small food container, a neoprene band simulating a diaphragm, an inflated balloon simulating a spleen, a tissue chord simulating intestine, and a body wash sponge simulating a collapsed lung. The evaluation comprised 3 sets of 5-point grading scale concerning appearance, necessary maneuvers, and ability to generate skills. Bowel reduction and suture efficacy was verified for each test., Setting: Minimally invasive surgery simulation room at Pediatric Surgery Department of Hospital Universitario de Vall d'Hebron, Barcelona, Spain., Participants: Volunteer residents and specialists of pediatric surgery., Results: Bowel reduction was possible in every test, with 1 spleen rupture, 1 bowel entrapment, and 2 inappropriate sutures due to tension. Most volunteers considered the general endoscopic vision (63.2%), external and internal dimensions (both 89.5%) to be highly similar; bowel reduction (68.4%) and diaphragm's manipulation and suture (57.9%) to be highly or very highly similar. Regarding its ability to generate skills, most considered it to be very or extremely useful concerning: camera handling (52.6%), working in small spaces and suture (both 100%), and tissue handling (63.2%). The least liked features were the colors and the diaphragm's tension. The size, portability, and the reproducibility were the most liked features., Conclusions: We consider this low cost and easily reproducible model to be realistic enough for CDH repair training, having the potential to be adapted for other simulations., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Thoracoscopic devices have become essential in general thoracic surgery. In the past 30 years, many reports about thoracoscopic surgery have expanded the indications to include malignant neoplasms. Various optional procedures including uniportal, non-intubated, robotic, and needlescopic techniques have been developed and more than 70% of lung cancer operations are currently performed using thoracoscopy in Japan. Although there are many choices for minimally invasive surgery, the long-term outcome of these options remains unclear. In addition, training systems for younger surgeons have not provided exposure to novel optional methods, as there are few high-volume centers in Japan.

Introduction: Pediatric surgeons rely on simulation courses to develop skills for safe minimally invasive repair of complex congenital anomalies. The majority of minimally invasive surgery (MIS) training courses occur during short "exposure courses" at annual conferences. Little data are available to support the benefit of these courses relative to the safe implementation of new skills. The purpose of this article is to determine the impact of an exposure course for advanced neonatal MIS on self-perceived comfort levels with independent performance of advanced MISs., Methods: Participants of a 4-hour hands-on course for neonatal MIS were surveyed regarding clinical practices and pre- and post-training perceived "comfort levels" of MIS skills for thoracoscopic esophageal atresia with tracheoesophageal fistula (tTEF) repair, thoracoscopic left upper lobe pulmonary lobectomy (tLobe), and laparoscopic duodenal atresia (lapDA) repair. Descriptive analyses were performed., Results: Seventeen participants completed pre- and postcourse surveys. The majority of participants had no prior experience with tLobe (59%) or lapDA (53%), and 35% had no experience with tTEF repair. Similarly, the majority were "not comfortable" with these procedures. After the short course, the majority of surgeons reported that they were "likely to perform" these operations within 6 months, despite low levels of baseline experience and comfort levels., Conclusion: An exposure training course led to immediate perception of increased skills and confidence. However, these courses typically do not provide basic tenets of expert performance that demands deliberate practice. Future course design should transition to a mastery learning framework wherein regular skill assessments, milestones, and unlimited education time are prioritized before implementation of the new skills.

Interventional pulmonology (IP) is a rapidly evolving subspecialty of pulmonary medicine. In the last 10 years, formal IP fellowships have increased substantially in number from five to now > 30. The vast majority of IP fellowship trainees are selected through the National Resident Matching Program, and validated in-service and certification examinations for IP exist. Practice standards and training guidelines for IP fellowship programs have been published; however, considerable variability in the environment, curriculum, and experience offered by the various fellowship programs remains, and there is currently no formal accreditation process in place to standardize IP fellowship training. Recognizing the need for more uniform training across the various fellowship programs, a multisociety accreditation committee was formed with the intent to establish common accreditation standards for all IP fellowship programs in the United States. This article provides a summary of those standards and can serve as an accreditation template for training programs and their offices of graduate medical education as they move through the accreditation process., (Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: For assessing the use of if simulation training on animal cadavers as a useful tool for training in pleuroscopy., Methods: The email-based cross-sectional study was conducted in December 2014 at Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore, Pakistan, and comprised respiratory physicians and trainees after their participation in a two-day hands-on training course on pleuroscopy and pleural medical procedures. The responses were analysed and the responses of physicians and trainees were compared., Results: Of the 44 individuals who attended the course and were contacted through emails, 38(86.4%) responded, including 20(52.6%) physicians and 18(47.3%) trainees. All the 38(100%) subjects uniformly accepted the utility of simulation training in enhancing education, improving skill, and improving confidence by repeated practice, and felt that the inclusion of animal models for learning fundamental pleuroscopic procedures can help a lot in teaching., Conclusions: Animal cadavers can be used as an effective teaching tool for pleuroscopy training.

Purpose: Thoracoscopic esophagectomy with the patient in the prone position (TEP) is now being performed as minimally invasive esophagectomy for esophageal cancer. This study examines the short-term outcomes and the learning curve associated with TEP., Methods: One surgeon ("Surgeon A") performed TEP on 100 consecutive patients assigned to three periods based on treatment order. Each group consisted of 33 or 34 patients. The outcomes of the three groups were compared to define the influence of surgeon expertise., Results: Outcomes improved as Surgeon A gained experience in performing this operation, as evidenced by reduced thoracic operative times between periods 1 and 2, and then between periods 2 and 3 (p = 0.0033 and p = 0.0326, respectively); an increased number of retrieved chest nodes between periods 1 and 2 (p = 0.0070); and a decline in recurrent laryngeal nerve (RLN) palsy between periods 2 and 3 (p = 0.0450). Period 2 was the pivotal period for each learning curve., Conclusions: An individual surgeon's learning curve over the course of 100 TEP procedures had three outcomes: a shortened operative time, a higher number of retrieved chest nodes, and a decreased rate of RLN palsy. Approximately 30-60 cases were needed to reach a plateau in the TEP procedure and a reduction in the morbidity rate.

Background: Although error identification and recovery skills are essential for the safe practice of surgery, they have not traditionally been taught or evaluated in residency training. This study validates a method for assessing error identification and recovery skills in surgical residents using a thoracoscopic lobectomy simulator., Methods: We developed a 5-station, simulator-based examination containing the most commonly encountered cognitive and technical errors occurring during division of the superior pulmonary vein for left upper lobectomy. Successful completion of each station requires identification and correction of these errors. Examinations were video recorded and scored in a blinded fashion using an examination-specific rating instrument evaluating task performance as well as error identification and recovery skills. Evidence of validity was collected in the categories of content, response process, internal structure, and relationship to other variables., Results: Fifteen general surgical residents (9 interns and 6 third-year residents) completed the examination. Interrater reliability was high, with an intraclass correlation coefficient of 0.78 between 4 trained raters. Station scores ranged from 64% to 84% correct. All stations adequately discriminated between high- and low-performing residents, with discrimination ranging from 0.35 to 0.65. The overall examination score was significantly higher for intermediate residents than for interns (mean, 74 versus 64 of 90 possible; p = 0.03)., Conclusions: The described simulator-based examination with embedded errors and its accompanying assessment tool can be used to measure error identification and recovery skills in surgical residents. This examination provides a valid method for comparing teaching strategies designed to improve error recognition and recovery to enhance patient safety., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.

Purpose: Minimally invasive esophagectomy (MIE) has less morbidity than the open approach. In particular, thoracoscopic esophagectomy in the prone position (TEP) has been performed worldwide. Using the cumulative sum control chart (CUSUM) method, this study aimed to confirm whether a trainee surgeon who learned established standards would become skilled in TEP with a shorter learning curve than that of the mentoring surgeon., Methods: Surgeon A performed TEP in 100 patients; the first 22 patients comprised period 1. His learning curve, defined based on the operation time (OT) of the thoracic procedure, was evaluated using the CUSUM method, and short-term outcomes were assessed. Another 22 patients underwent TEP performed by surgeon B, with outcomes compared to those of surgeon A's period 1., Results: Using the CUSUM chart, the peak point of the thoracic procedure OT occurred at the 44th case in surgeon A's experience of 100 cases. With surgeon A's first 22 cases (period 1), the peak point of the thoracic procedure OT could not be confirmed and graph is expanding soaring at CUSUM chart. The CUSUM chart of surgeon B's experience of 22 cases clearly indicated that the peak point of the thoracic procedure OT occurred at the 17th case. The rate of recurrent laryngeal nerve palsy for surgeon B (9 %) was significantly lower than for surgeon A in period 1 (36 %) (p = 0.0266)., Conclusions: There is some possibility for a trainee surgeon to attain the required basic skills to perform TEP in a relatively short period of time using a standardized procedure developed by a mentoring surgeon. The CUSUM method should be useful in evaluating trainee competence during an initial series of procedures, by assessing the learning curve defined by OT.

Unlabelled: We present the results of the validation of an inanimate model created for training thoracoscopic treatment of esophageal atresia with lower tracheoesophageal fistula (EA/TEF)., Materials and Methods: We used different domestic materials such as a piece of wood (support), corrugated plastic tubes (PVC) of different sizes to simulate ribs, intercostal spaces, trachea and spine and tubular latex balloons to simulate the esophagus and lungs to make the basic model. This device was inserted into the thoracic cavity of a rubber dummy simulating a 3kg newborn with a work area volume of 50ml. The model was designed taking into account the experience of doing this procedure in neonates. The cost of the materials used was 50 US$. Regular video endoscopic equipment and 3mm instruments were used. Thirty-nine international faculty or pediatric surgeons attending hands on courses with different levels of training in minimal invasive surgery (MIS) repair of EA/TEF performed the procedure in the model. We compared the performance of the practitioners with their experience in thoracoscopic repair of EA. A Likert-type scale was used to evaluate results. Previous experience in MIS, anatomical appearance of the model, surgical anatomy compared to a real patient, and utility as a training method were analyzed. We also used a checklist to assess performance. We evaluated: number of errors and types of injuries, quality of the anastomosis, and duration of procedure. To analyze the results we used a T-test, chi-square test and Excel® database to match up some results., Results: Thirty-nine questionnaires were completed. Seven surgeons were experts (≥30 TEF/EA repairs as surgeon), 10 had intermediate level of experience (5 to 29 repairs as surgeon) and 22 were beginners (less than 5 repairs). To simplify the analysis we divided the respondents into low experience LE (<5 real procedures-beginners; n=22) and high experience HE (intermediate, 10; and experts, 7; n=17). In relation to the anatomical characteristics of the model, 94.48% (n=37) respondents considered that the model has a high degree of similarity or good similarity; in relation to surgical anatomy 88.2% (n=34) respondents considered that the model has a high degree of similarity or good similarity; 87.17% (n=34) respondents considered that the model can generate a good amount of skills and/or can generate great majority of skills to EA/TEF repair; and 12.82% (n=5) respondents consider that it can generate some skills or a few skills, only in relation to trocar placement, one of the surveyed items. The number of errors was 29±7 SD (20 to 51) for the low experience group (LE) and 9±6 SD (1 to 20) for the high experience group (HE) (P value<0.0001). Time in minutes was significantly lower in the HE group (40±9 SD; 26 to 58min), in relation with LE (81±19 SD; 49 to 118min) (P<0.0001, T-test). Deficient or incomplete anastomosis also showed differences: 7 (32%) in the LE group and 1 (6%) in the HE group (P = 0.04, chi-square test). We saw a correlation between the previous experience of the surgeon and their performance in the model considering operating time, quality of anastomosis and peripheral tissue damage. According to the suggestions registered in the questionnaires, we have now improved the model. We have also started using it in a scenario to simulate the whole neonatal MIS operative room setting and team work., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: We previously developed a pediatric thoracoscopic surgical simulator and showed its construct validity. In this study, the same skill assessment experiments were conducted in an additional 31 surgeons and the results of 53 surgeons in total were analyzed., Methods: A suture pad with force sensors was placed in a rapid-prototyped pediatric chest model of a 1-year-old patient. Participants completed the endoscopic intracorporeal suturing and knot-tying task, both in the pediatric chest model setup and in a box trainer setup. The task was evaluated using eight metrics: the 29-point checklist score, error score, number of manipulations, task completion time, force index, width of the pad's slit after suturing, and right and left tool paths., Results: The 53 participants included skilled surgeons certified by the Endoscopic Surgical Skill Qualification (ESSQ) system (n = 8) and unskilled surgeons without the certification (n = 45). The skilled surgeons showed significantly better performance than the unskilled surgeons in six metrics in the pediatric chest model setup. In contrast, no significant differences between the two groups were observed in the box trainer setup. Upon comparison between the setups, the unskilled surgeons showed worse results in six metrics in the pediatric chest model than in the box trainer, whereas the skilled surgeons showed equivalent performance in both setups., Conclusions: Our pediatric thoracoscopic surgical simulator was superior to the conventional box trainer for identifying skilled surgeons. The skilled surgeons showed excellent performance even in the intricate pediatric chest model, providing quantified targets for young pediatric surgeons' training.

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.

Purpose: Thoracoscopic esophageal atresia (EA)/tracheoesophageal fistula (TEF) repair is technically challenging. We have previously reported our experiences with a high-fidelity hybrid model for simulation-based educational instruction in thoracoscopic EA/TEF, including the high cost of the tissue for these models. The purposes of this study were (1) to create a low-cost synthetic tissue EA/TEF repair simulation model and (2) to evaluate the content validity of the synthetic tissue simulator., Materials and Methods: Review of the literature and computed tomography images were used to create computer-aided drawings (CAD) for a synthetic, size-appropriate EA/TEF tissue insert. The inverse of the CAD image was then printed in six different sections to create a mold that could be filled with platinum-cured silicone. The silicone EA/TEF insert was then placed in a previously described neonatal thorax and covered with synthetic skin. Following institutional review board-exempt determination, 47 participants performed some or all of a simulated thoracoscopic EA/TEF during two separate international meetings (International Pediatric Endosurgery Group [IPEG] and World Federation of Associations of Pediatric Surgeons [WOFAPS]). Participants were identified as "experts," having 6-50 self-reported thoracoscopic EA/TEF repairs, and "novice," having 0-5 self-reported thoracoscopic EA/TEF repairs. Participants completed a self-report, six-domain, 24-item instrument consisting of 23 5-point rating scales and one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (interitem consistency) was estimated using Cronbach's alpha., Results: A review of the participants' ratings indicates there were no overall differences across sites (IPEG versus WOFAPS, P=.84) or experience (expert versus novice, P=.17). The highest observed averages were 4.4 (Value of Simulator as a Training Tool), 4.3 (Physical Attributes-chest circumference, chest depth, and intercostal space), and 4.3 (Realism of Experience-fistula location). The lowest observed averages were 3.5 (Ability to Perform-closure of fistula), 3.7 (Ability to Perform-acquisition target trocar sites), 3.8 (Physical Attributes-landmark visualization), 3.8 (Ability to Perform-anastomosis and dissection of upper pouch), and 3.9 (Realism of Materials-skin). The Global Rating Scale was 2.9, coinciding with a response of "this simulator can be considered for use in neonatal TEF repair training, but could be improved slightly." Material costs for the synthetic EA/TEF inserts were less than $2 U.S. per insert., Conclusions: We have successfully created a low-cost synthetic EA/TEF tissue insert for use in a neonatal thoracoscopic EA/TEF repair simulator. Analysis of the participants' ratings of the synthetic EA/TEF simulation model indicates that it has value and can be used to train pediatric surgeons, especially those early in their learning curve, to begin to perform a thoracoscopic EA/TEF repair. Areas for model improvement were identified, and these areas will be the focus for future modifications to the synthetic EA/TEF repair simulator.

Purpose: Pediatric endoscopic surgery requires special surgical skills because of the small working space and tissue fragility. This article presents a video-based skill assessment method for endoscopic suturing using a pediatric chest model., Materials and Methods: A commercial suture pad was placed in a rapid-prototyped pediatric chest model of a 1-year-old patient to simulate the thoracoscopic repair of esophageal atresia type C. Twenty-eight pediatric surgeons (9 experts, 9 intermediates, and 10 trainees) performed an endoscopic intracorporeal suturing and knot-tying task both in the pediatric chest model and in a box trainer. The tasks were video-recorded and rated by two blinded observers using the 29-point checklist method and a suturing errors score sheet method. The task completion time and the number of needle manipulations were measured., Results: The expert group showed better performance than the intermediate and trainee groups in the pediatric chest model, and the differences were larger than those in the box trainer. Significant differences between the expert and the trainee groups were observed in the items related to safety such as the skills for keeping the needle in view at all times. Significant differences between the expert and intermediate groups were observed in the items related to task quality and efficiency such as the smoothness of knot tying and the number of needle manipulations., Conclusions: Video-based skill assessment of endoscopic suturing using the pediatric chest model and a box trainer distinguished pediatric endoscopic surgeons according to their clinical experience, and pediatric-specific skills were identified.

Purpose: Thoracoscopic lobectomy in infants requires advanced minimally invasive skills. Simulation-based education has the potential to improve complex procedural skills without exposing the patient to undue risks. The study purposes were (1) to create a size-appropriate infant lobectomy simulator and (2) to evaluate validity evidence to support or refute its use in surgical education., Materials and Methods: In this Institutional Review Board-exempt study, a size-appropriate rib cage for a 3-month-old infant was created. Fetal bovine tissue completed the simulator. Thirty-three participants performed the simulated thoracoscopic lobectomy. Participants completed a self-report, 26-item instrument consisting of 25 4-point rating scales (from 1=not realistic to 4=highly realistic) and a one 4-point Global Rating Scale. Validity evidence relevant to test content and response processes was evaluated using the many-facet Rasch model, and evidence of internal structure (inter-item consistency) was estimated using Cronbach's alpha., Results: Experienced surgeons (observed average=3.6) had slightly higher overall rating than novice surgeons (observed average=3.4, P=.001). The highest combined observed averages were for the domain Physical Attributes (3.7), whereas the lowest ratings were for the domains Realism of Experience and Ability to Perform Tasks (3.4). The global rating was 2.9, consistent with "this simulator can be considered for use in infant lobectomy training, but could be improved slightly." Inter-item consistency for items used to evaluate the simulator's quality was high (α=0.90)., Conclusions: With ratings consistent with high physical attributes and realism, we successfully created an infant lobectomy simulator, and preliminary evidence relevant to test content, response processes, and internal structure was supported. Participants rated the model as realistic, relevant to clinical practice, and valuable as a learning tool. Minor improvements were suggested prior to its full implementation as an educational and testing tool.

The clinical practice of pulmonary and critical care medicine requires procedural competence in many technical domains, including vascular access, airway management, basic and advanced bronchoscopy, pleural procedures, and critical care ultrasonography. Simulation provides opportunities for standardized training and assessment in procedures without placing patients at undue risk. A growing body of literature supports the use and effectiveness of low-fidelity and high-fidelity simulators for procedural training and assessment. In this manuscript by the Skills-based Working Group of the American Thoracic Society Education Committee, we describe the background, available technology, and current evidence related to simulation-based skills training within pulmonary and critical care medicine. We outline working group recommendations for key procedural domains.

Background and Objectives: We sought to develop a simulation model that accurately replicates the challenges of the thoracoscopic intrathoracic anastomosis. This model is intended to serve as a teaching tool during the introduction to, and development of, the skills required to perform a thoracoscopic intrathoracic anastomosis during an Ivor Lewis minimally invasive esophagectomy., Methods: The simulation model uses porcine tissue placed within an artificial hemithorax and covered with a synthetic skin. The model is draped to simulate a realistic operative setting, and ports are placed in standard surgical fashion. Dissection of the esophagus from the mediastinum is then performed, followed by the creation of an esophagogastric anastomosis. The effectiveness of the training model was evaluated using volunteer general and thoracic surgery residents at varying stages of surgical training. The quality of the anastomoses created were evaluated using both objective and subjective criteria, and successful anastomoses were tested for leaks using hydrostatic pressure., Results: Objective evaluation showed that successful completion of the anastomosis task increased with the number of attempts, with 100% of participants successfully completing an anastomosis by the final attempt. The time to completion of a successful anastomosis also improved across successive attempts. Moreover, objective measures also showed improvement over time based on the graded quality of the completed anastomosis., Conclusion: As surgical techniques continue to evolve, so must the means by which they are taught. This simulation model shows effectiveness in the training of general and thoracic surgery residents performing thoracoscopic intrathoracic anastomosis during the Ivor Lewis minimally invasive esophagectomy.

Introduction: Though minimally invasive pediatric surgery has become more widespread, pediatric-specific surgical skills have not been quantitatively assessed., Material and Methods: As a first step toward the quantification of pediatric-specific surgical skills, a pediatric chest model comprising a three-dimensional rapid-prototyped pediatric ribcage with accurate anatomical dimensions, a suturing skin model with force-sensing capability, and forceps with motion-tracking sensors were developed. A skill assessment experiment was conducted by recruiting 16 inexperienced pediatric surgeons and 14 experienced pediatric surgeons to perform an endoscopic intracorporeal suturing and knot-tying task in both the pediatric chest model setup and the conventional box trainer setup., Results: The instrument motion measurement was successful in only 20 surgeons due to sensor failure. The task completion time, total path length of instruments, and applied force were compared between the inexperienced and experienced surgeons as well as between the box trainer and chest model setups. The experienced surgeons demonstrated better performance in all parameters for both setups, and the pediatric chest model was more challenging due to the pediatric features replicated by the model., Conclusion: The pediatric chest model was valid for pediatric skill assessment, and further analysis of the collected data will be conducted to further investigate pediatric-specific skills.

Background: Thoracoscopic lobectomy is a safe and effective procedure; however, the ways by which to incorporate this technically demanding procedure into residency training is still unknown. We reported on the outcomes of thoracoscopic lobectomies performed by a single thoracic resident, who was simultaneously undergoing training for both open and thoracoscopic lobectomies., Patients and Methods: Between January 2010, and May 2011, data from 87 consecutive thoracoscopic lobectomies that were performed by a trainee surgeon (B.-Y.W.) were prospectively obtained. Data were grouped into the first 30 and subsequent 57 cases. Patient characteristics, operative data, complications, and surgical pathology were analyzed., Results: The mean operating time in group 2 was significantly lower compared with group 1 (264.0 ± 45.9 min in group 1 vs. 197.5 ± 57.7 min in group 2; p<0.001). There were no mortalities in both the groups and no significant differences in postoperative complications., Conclusions: Thoracoscopic lobectomy can be taught to a nonexperienced thoracic resident during an open procedure without compromising the safety of patients. It appears that surgical performance reaches a plateau after the completion of 30 cases., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Video-assisted thoracic surgery is gradually replacing conventional open thoracotomy as the method of choice for the treatment of early-stage non-small cell lung cancers, and thoracic surgical trainees must learn and master this technique. Simulation-based training could help trainees overcome the first part of the learning curve, but no virtual-reality simulators for thoracoscopy are commercially available. This study aimed to investigate whether training on a laparoscopic simulator enables trainees to perform a thoracoscopic lobectomy., Methods: Twenty-eight surgical residents were randomized to either virtual-reality training on a nephrectomy module or traditional black-box simulator training. After a retention period they performed a thoracoscopic lobectomy on a porcine model and their performance was scored using a previously validated assessment tool., Results: The groups did not differ in age or gender. All participants were able to complete the lobectomy. The performance of the black-box group was significantly faster during the test scenario than the virtual-reality group: 26.6 min (SD 6.7 min) versus 32.7 min (SD 7.5 min). No difference existed between the two groups when comparing bleeding and anatomical and non-anatomical errors., Conclusion: Simulation-based training and targeted instructions enabled the trainees to perform a simulated thoracoscopic lobectomy. Traditional black-box training was more effective than virtual-reality laparoscopy training. Thus, a dedicated simulator for thoracoscopy should be available before establishing systematic virtual-reality training programs for trainees in thoracic surgery.

Background/aim: This study evaluated the usefulness of a Bochdalek hernia rabbit model as a tool for advanced thoracoscopic training, teaching the specific skills required for thoracoscopic repair of congenital diaphragmatic hernia., Materials and Methods: An incision was made in the Bochdalek triangle of 25 New Zealand rabbits (weighing 3-3.5 kg) to induce an experimental diaphragmatic hernia. At 72 hours later, a thoracoscopic repair of the hernia as described for newborns was performed by 25 pediatric surgeons divided into two groups: expert and novice. The tasks assessed were organ relocation and diaphragm suture. A visual analog scale was used to evaluate technical performance. The objective performance measure was completion time. Complications were recorded, and suture quality was scored. The surgeons evaluated the model by completing a questionnaire, grading items on a 5-point scale., Results: All 25 animals developed a diaphragmatic hernia with protrusion of the intestine into the thoracic cavity. Expert trainees had significantly shorter completion times and better performance scores than novices. Experts also received higher scores for suture quality. Five novices caused perforations or bleeding, but no experts did. The surgeons rated the model positively, highlighting the similarities between the model and newborn hernias and its usefulness for pediatric training programs., Conclusions: The Bochdalek hernia rabbit model can be used to detect different levels of experience in pediatric thoracoscopy. This realistic and easily reproducible model can help to perfect thoracoscopic skills in a realistic recreation of a pediatric Bochdalek hernia repair.

Introduction: An increasing proportion of thoracic procedures are performed using video-assisted thoracic surgery. This minimally invasive technique places special demands on the surgeons. Using simulation-based training on artificial models or animals has been proposed to overcome the initial part of the learning curve. This study aimed to investigate the effect of simulation-based training and to compare self-guided and educator-guided training., Methods: The study included a surgeon group (n = 10) and 30 randomized novices in 3 groups. A control group (n = 10) and the group of surgeons (n = 10) were tested with no previous simulator training. A self-guided training group (n = 10) and an educator-guided training group (n = 10) trained for 3 hours on 3 scenarios of increasing fidelity and difficulty before taking a standardized test consisting of performing a wedge resection on a porcine lung, which was recorded and assessed blindly and independently by 2 thoracoscopic experts using a modified version of a validated assessment tool., Results: Interrater reliability was acceptable (Spearman ρ = 0.73, P < 0.001). The control group and the self-guided training group performed significantly worse than the experienced surgeons (P = 0.012 and P = 0.010, respectively). There was no significant difference between the educator-guided training group and the experienced surgeons (P = 0.271)., Conclusions: This randomized study concerning simulation-based training for thoracoscopy showed that 3 hours of intensive simulator training with a dedicated educator enables novices to perform an acceptable wedge resection in a simple, simulated model. Although not significant, it seemed that having an educator present during training had a beneficiary effect. Transfer studies are required for further conclusions.

Background: Pleuroscopy is considered a safe procedure with a high diagnostic accuracy but this record is based on studies published by pulmonologists experienced in performing the procedure., Methods: Review of 40 consecutive patients who underwent semirigid pleuroscopy by a pulmonary fellow under the supervision of a pulmonologist., Results: Pleuroscopy was performed for diagnosis of pleural effusion (n=33), or treatment of pleural effusion (n=4) or pneumothorax (n=3). The mean age±SD of the patients was 58.23±12.98 years and 23 patients were male. Pleuroscopy was performed with a flex-rigid pleuroscope under local anesthesia and conscious sedation. An ultrasound was used to choose the entry site. The dose of midazolam and fentanyl used was 6.45±2.87 mg and 173.39±77.17 mcg, respectively. The duration of the procedure was 69.3±25.3 minutes. The amount of pleural fluid removed was 1.5±0.94 L. The overall diagnostic accuracy of pleuroscopy was 87.8%, and the sensitivity, specificity, negative and positive predictive value for malignancy was 93.9%, 100%, 92.3% and 100%, respectively. There were a few complications: desaturation (n=2), hypotension (n=5), extensive subcutaneous emphysema (n=3), and persistent air leak (n=1). There was no case of significant bleeding or death from the procedure. Six of the 7 cardiopulmonary complications occurred during the first 4 procedures performed by the fellows., Conclusions: The diagnostic accuracy of pleuroscopy remains high in the hands of pulmonary fellows. However, the procedure can be associated with a slightly higher rate of complications when performed by fellows in training, especially in the early part of their learning curve. Most of the few complications observed were not caused by the procedure per se and resulted from over-zealous use of medications for conscious sedation.

Purpose: We sought to create and validate a high fidelity, anatomically correct real tissue simulation model for thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair., Methods: A scale reproduction of a neonatal rib cage was created. Surgically modified (EA/TEF) fetal bovine tissue completed the simulator. Nine pediatric surgery fellows and two attending pediatric surgeons (n=11) performed the simulated thoracoscopic EA/TEF repair. Participants completed a self-report rating scale, ranging from 1 (Don't know) to 5 (Highly realistic). Construct validity relevant to test content was evaluated by examining the ratings using the many-Facet Rasch model., Results: Analyses indicated no differences when comparing faculty (Observed Average (OA)=4.5/5.0) to fellow (OA=3.3) ratings, p=.71. In descending order, observed averages of the domains were 4.7 (Relevance), 4.5 (Physical attributes), 4.5 (Realism of materials), 4.4 (Ability to perform task), and 4.2 (Value). The observed Global opinion rating indicated the simulator can be considered for teaching thoracoscopic EA/TEF repair but could be improved slightly., Conclusions: Fellow and faculty ratings indicated the simulator was valuable as a learning tool with minor modifications. Comments were consistent with high physical attribute ratings., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to assess the experience of a high-volume centre with thoracolaparoscopy radical oesophagectomy and to evaluate the feasibility, tumour clearance, the learning curve and reproducibility of this technique., Methods: Eighty patients with thoracic oesophageal cancer who underwent thoracolaparoscopic oesophagectomy (TLE) were enrolled in this study. Two attending surgeons (Mingqiang Kang and Ruobai Lin) independently performed the procedure as operating surgeons. The 60 patients who had surgery performed on them by the senior attending surgeon, Mingqiang Kang, were divided into three groups of 20 patients: groups A, B and C. The results from the three groups were compared in order to detect any changes in the success of TLE as a way of monitoring the development of the surgeon's technical skill. Another 20 patients had surgery performed on them by the new attending surgeon, Ruobai Lin, and were classified into the fourth group, D. The results from Group D were compared with those of the other three groups to evaluate the reproducibility of our technique., Results: There was no significant difference between the four groups with respect to age, gender, location of tumour or staging. The duration of both the thoracoscopic and laparoscopic procedures was significantly longer in Group A. The amount of estimated blood loss was significantly more in Group A than in the other groups. The number of lymph nodes dissected was similar in Groups A and D, whereas that of retrieved nodes was larger in Groups B and C. There was no significant difference in the incidence of respiratory complications, recurrent nerve palsy, anastomotic leaks, arrhythmia, chylothorax and delayed gastric emptying among the four groups., Conclusions: When TLE procedures are started in units with a large volume of oesophageal resections, and when there is support from colleagues within the unit, transition from open to TLE can be achieved safely, with a satisfactory oncological outcome. A plateau of TLE skill was reached after 40 cases had been performed. If mini-fellowship training with supervision from senior surgeons is used, it is possible for a new attending surgeon to attain the requisite basic skill to perform TLE in a relatively short period of time.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) is a technically challenging surgical procedure. This congenital anomaly is rare; therefore, training opportunities for surgical trainees are limited. There are currently no validated simulation tools available to help train pediatric surgery trainees. The simulator that was developed is a low-cost, reusable model. It simulates the right side of a term neonate chest and contains a tissue block that has been surgically modified to replicate the anatomy of EA/TEF.

Training in interventional pulmonology procedures is increasing in popularity. However, the nature of training is difficult to define, particularly with respect to an adequate number of cases. These guidelines approach training not just from a modest number of supervised cases, but also from a range of educational and outcome targets which give a rounded approach to the issue. These include prerequisite skills from basic procedures, the place of simulated training, formal simulation testing, modest procedural outcome and side effect targets, audit presentations, ongoing reading, and hands-on training expectations. All of this would still be under the supervision of an experienced trainer., (© 2012 The Authors. Respirology © 2012 Asian Pacific Society of Respirology.)

Background: Research suggests a benefit from a skills curriculum emphasizing error prevention, identification, and management. Our purpose was to identify common errors committed by trainees during simulated thoracoscopic lobectomy for use in developing an error-based curriculum., Methods: Twenty-one residents (postgraduate years 1 to 8) performed a thoracoscopic left upper lobectomy on a previously validated simulator. Videos of the procedure were reviewed in a blinded fashion using a checklist listing 66 possible cognitive and technical errors., Results: Of the 21 residents, 15 (71%) self-reported completing the anatomic lobectomy; however, only 7 (33%) had actually divided all of the necessary structures correctly. While dissecting the superior pulmonary vein, 16 residents (76%) made at least one error. The most common (n=13, 62%) was dissecting individual branches rather than the entire vein. On the bronchus, 14 (67%) made at least one error. Again, the most common (n=9, 43%) was dissecting branches. During these tasks, cognitive errors were more common than technical errors. While dissecting arterial branches, 18 residents (86%) made at least one error. Technical and cognitive errors occurred with equal frequency during arterial dissection. The most common arterial error was excess tension on the vessel (n=10, 48%)., Conclusions: Curriculum developers should identify skill-specific technical and judgment errors to verify the scope of errors typically committed. For a thoracoscopic lobectomy curriculum, emphasis should be placed on correct identification of anatomic landmarks during dissection of the vein and airway and on proper tissue handling technique during arterial dissection., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The advent of minimally invasive esophagectomy (MIE) attempts to decrease postoperative complications and mortality for this high-risk procedure. This review examines techniques in MIE, associated outcomes, and offers a critical appraisal of the literature surrounding this procedure. A Pubmed search was conducted for "minimally invasive esophagectomy" and associated synonyms. In addition, we analyze the outcomes at our institution through a prospectively maintained database. With varied techniques and utilization of different endpoints it is difficult to draw concrete conclusions from the current literature. Overall, however, there is no strong trend toward deceased mortality or decreased pulmonary complications from MIE, but there is a trend toward decreased intraoperative blood loss and shorter intensive care unit and ward stays. Until future studies are completed, MIE remains a useful tool in the armamentarium of the esophageal surgeon, and should be used not in exclusion of other approaches should patient or tumor factors dictate otherwise.

Objectives: Although simulation is considered integral to general surgery training, its role has only recently been recognized in thoracic surgical education, perhaps due to a lack of widely available, validated simulators for advanced thoracic procedures. This study evaluates the construct, content and face validity of an inexpensive, easily reproducible simulator for teaching thoracoscopic lobectomy., Methods: Construct validity (ability of the simulator to discriminate between users of different skill levels) was assessed by having surgical trainees perform a lobectomy on the simulator. Participants were divided into three groups (experienced, intermediate and novice) based on self-reported experience with minimally invasive surgery. After instruction and practice time to limit the effect of any simulator-specific learning curve, each performed a left upper lobectomy that was scored using a standardized assessment tool incorporating total time plus weighted penalty minutes assigned for errors. Content validity (simulator requires same steps and decision-making as a clinical lobectomy) was assessed using a Likert scale by those participants who had previously seen a thoracoscopic lobectomy in a patient., Results: Thirty-one residents participated in the study (12 experienced, 6 intermediate and 13 novice). All 12 experienced participants completed the lobectomy. The other groups were less successful with 4 of 6 in the intermediate group and 5 of 13 in the novice group completing the lobectomy (P = 0.004). The mean times for lobectomy + penalty minutes were 35 + 6.8 (experienced), 50 + 13 (intermediate) and 54 + 20 (novice). Differences between groups were statistically significant for experienced vs. novice (P < 0.001) and experienced vs. intermediate (P < 0.04). Content validity was assessed by the 18 participants who had previously seen a thoracoscopic lobectomy with a mean of 9.2 of 10 possible points., Conclusions: The thoracoscopic lobectomy simulator used in this study demonstrates acceptable validity and can be a useful tool for teaching thoracoscopic lobectomy to trainees or experienced surgeons.

Pediatric minimally invasive surgery is a rapidly developing field with a steep learning curve for each new procedure that is developed and integrated into practice. The European consensus is that the training across the learning curve should not be on the patients. Simulation is a widely accepted methodology to shorten the learning curve. Training on animal models is an advanced form of simulation. This helps to reduce morbidity and the costs of patient care. This article describes our 3 years of experience in the development of animal models for training in pediatric minimally invasive surgery.

Gastroesophageal reflux disease (GERD) is the most frequent benign disorder of the upper gastrointestinal (GI) tract and other defined disease entities, such as achalasia and diffuse esophageal spasm, also belong to this group. In addition to surgical therapy, medicinal therapy also has an important role in all 3 of these disorders. Therefore, it is very important to follow precise indication criteria based on diagnostic evaluation and patient selection as well as to use an optimal operative technique.The therapeutic spectrum for achalasia varies from Botox injections and endoscopic dilatation to laparoscopic myotomy which achieves a success rate up to 90%.Patients with diffuse spasm suffer from severe dysphagia, thoracic pain and burning sensations and even respiratory problems. Surgical therapy consists of thoracoscopic long myotomy and in selective cases with persisting pain even esophagectomy and gastric pull-up.Therapeutic options for GERD predominantly involve conservative medicinal therapy with proton pump inhibitors and selective laparoscopic antireflux procedures. Minimally invasive techniques have led to a higher acceptance of surgical therapy. The two major procedures most frequently used are total Nissen fundoplication and posterior partial Toupet fundoplication.

Thoracoscopy is currently the gold standard for the diagnosis and treatment of pleural diseases. Its diagnostic yield is 95% in patients with malignant pleural disease, with approximately 90% successful pleurodesis for malignant pleural effusion and 95% for pneumothorax. At the same time, thoracoscopy constitutes an important tool in the research of pleural pathophysiology and molecular biology. The improvement of technology has provided important tools to thoracoscopy, such as autofluorescence, narrow band imaging, and infrared light, used in clinical and basic research in many disorders involving the pleura. For these reasons, training in thoracoscopy should be considered equally important as training in bronchoscopy for residents in respiratory medicine., (Copyright © 2011 S. Karger AG, Basel.)

Background: Despite the paradigm shift from process to competency-based education, no study has explored how competency-based metrics might be used to assess short-term effectiveness of thoracoscopy-related postgraduate medical education., Objectives: To assess the use of a single-group, pre-/post-test model comprised of multiple-choice questions (MCQ) and psychomotor skill measures to ascertain the effectiveness of a postgraduate thoracoscopy program., Methods: A 37-item MCQ test of cognitive knowledge was administered to 17 chest physicians before and after a 2-day continued medical education-approved program. Pre- and post-course technical skills were assessed using rigid videothoracoscopy simulation stations. Competency-based metrics (mean relative gain, mean absolute gain, and class-average normalized gain ) were calculated. A >30% was used to determine curricular effectiveness., Results: Mean cognitive knowledge score improved significantly from 20.9 to 28.7 (7.8 ± 1.3 points, p < 0.001), representing a relative gain of 37% and an absolute gain of 21%. Mean technical skill score improved significantly from 5.20 to 7.82 (2.62 ± 0.33 points, p < 0.001), representing a relative gain of 50% and an absolute gain of 33%. Non-parametric testing confirmed t test results (p < 0.001). Class-average normalized gains were 48 and 92%, respectively., Conclusion: Competency-based metrics, including class-average normalized gain, can be used to assess course effectiveness and to determine if a program meets predesignated objectives of knowledge acquisition and psychomotor technical skill., (Copyright © 2010 S. Karger AG, Basel.)