Benchmark Development for Fundamental Arthroscopic Skills Using a Simulation-Based Training Program: Observational Study.

Changes to Training Practices during a Pandemic - The Experience of the Irish National Trauma & Orthopaedic Training Scheme

There is high demand for arthroscopic procedures in the developing world. Simulation allows trainees to develop basic arthroscopic skills away from theatre, where there may be reduced surgical exposure compared...

We aim to develop quantitative performance metrics and a deep learning model to objectively assess surgery skills between the novice and the expert surgeons for arthroscopic rotator cuff surgery. These proposed metrics can be used to give the surgeon an objective and a quantitative self-assessment platform. Ten shoulder arthroscopic rotator cuff surgeries were performed by two novices, and fourteen were performed by two expert surgeons. These surgeries were statistically analyzed. Two existing evaluation systems: Basic Arthroscopic Knee Skill Scoring System (BAKSSS) and the Arthroscopic Surgical Skill Evaluation Tool (ASSET), were used to validate our proposed metrics. In addition, a deep learning-based model called Automated Arthroscopic Video Evaluation Tool (AAVET) was developed toward automating quantitative assessments. The results revealed that novice surgeons used surgical tools approximately 10% less effectively and identified and stopped bleeding less swiftly. Our results showed a notable difference in the performance score between the experts and novices, and our metrics successfully identified these at the task level. Moreover, the F1-scores of each class are found as 78%, 87%, and 77% for classifying cases with no-tool, electrocautery, and shaver tool, respectively. We have constructed quantitative metrics that identified differences in the performances of expert and novice surgeons. Our ultimate goal is to validate metrics further and incorporate these into our virtual rotator cuff surgery simulator (ViRCAST), which has been under development. The initial results from AAVET show that the capability of the toolbox can be extended to create a fully automated performance evaluation platform.

Die praktische chirurgische Ausbildung wird in der Orthopädie und Unfallchirurgie durch den steigenden Kostendruck in den Kliniken sowie die Verlagerung vieler Operationen in den ambulanten Bereich immer schwieriger. Das betrifft besonders die Arthroskopie, die zudem hohe Anforderungen an die Fähigkeiten des Operateurs stellt. In den letzten 20 Jahren wurden daher zahlreiche Arthroskopiesimulatoren entwickelt. Dabei handelt es sich um virtuelle Desktopsysteme, die mit einem Gelenksimulator gekoppelt sind und eine taktile Rückkopplung erlauben. Auf diese Weise können arthroskopische Basisfähigkeiten (z. B. Triangulation) oder auch arthroskopische Operationen (z. B. partielle Meniskektomie) trainiert werden. Die Systeme ermöglichen eine Erfolgskontrolle durch die Erfassung verschiedener Parameter (Operationszeit, Kamera‑/Instrumentenpfadlänge, Knorpelberührungen). Es existieren bereits Simulatoren für alle großen Gelenke. Mittlerweile liegen Daten zur Augenscheinvalidität, Inhaltsvalidität, Konstruktvalidität und zur Transfervalidität dieser Systeme vor. Die erlernten Fähigkeiten lassen sich daher auf den Erfolg im Operationssaal übertragen. Ungelöst ist bisher die Kosteneffizienz dieser Systeme. Von den Desktop-Gelenkmodell-Systemen müssen immersive Virtual-Reality(VR)-Systeme unter Verwendung von 3‑D-Brillen und taktilen Handsensoren abgegrenzt werden. Der Teilnehmende tritt der Applikation dabei meist als Avatar bei. Daher eignen sich immersive Systeme besonders zur Simulation offener Operationen (z. B. Hüftendoprothetik). Erste Studien haben auch für den Einsatz der immersiven virtuellen Realität Evidenz für Inhalts‑, Konstrukt- und Transfervalidität beim Training verschiedener offener Operationen gezeigt. Hier sind in Zukunft weitere Entwicklungen zu erwarten.

: Simulation tools continue to play an important part in surgical education, particularly allowing junior trainees an opportunity to familiarize themselves with various procedures that they either have not been exposed to or have not had enough repetition to feel confident enough to execute. It is particularly relevant when surgical training is interrupted due to unforeseen circumstances (i.e., coronavirus disease 2019, also called COVID-19) or to personal reasons (i.e., pregnancy, leave of absence). The ability to remotely work on technical skills has tremendous value and is certainly one of the reasons that we have continued to develop new surgical simulation tools, particularly in the field of plastic surgery. A review of the major surgical simulation and anatomy software tools available within the various subdivisions of plastic surgery such as craniofacial, microsurgery, aesthetic, hand/upper extremity and burn was performed. We also reviewed some of the simulation tools available in other surgical specialties and evaluated them for fit and utility in plastic and reconstructive surgery (PRS) surgical education. Our study shows that while various surgical simulators have been developed in PRS over the years, there remains a gap in terms of the ability for residents and trainees to acquire real-life skills remotely along with the capability to receive live feedback from faculty. This review shows that further tools need to be developed to optimize the acquisition and maintenance of surgical skills in a remote fashion. Taken together, it provides an overview of the evolution of surgical simulation education within plastic surgery.

Development and Validation of a Basic Arthroscopy Skills Simulator

Invited Commentary

The Grapefruit: An Alternative Arthroscopic Tool Skill Platform

The research theme of this investigation is driven by a strong clinical need for new and improved technology to help the modern surgeon. Since the beginning of the 21st century, the emergence of innovative technologies made further advances in minimal access surgery possible. Surgical techniques have evolved rapidly, for example the introduction of minimally invasive surgery (MIS) and robotically-assisted MIS which have improved outcomes for patients with faster recovery, reduced post-operative pain and fewer scars. For such a reason, there is an increasing need to develop innovative en- gineering solutions to some of the challenges being faced as surgery evolves to help surgeons to achieve the best possible clinical outcome and also to develop solutions helping to reduce costs and improve quality. As a matter of fact, robotic surgery and medical simulator addressed the limitations of medical procedures, thus revolutionizing minimal access surgery. First of all, with the introduction of robotics in the operating room, an evolutionary stage in the development of surgical technique was achieved to enhance the control and the visual field of the surgeon. It can be stated that this new approach was patient oriented as it brings several critical advantages for him: damage to healthy tissue is minimal; patients hospitalization is reduced to an average of 1.2 days; psychological impact of the procedure upon the patient is significantly lower; the risk of an unwanted infection is almost zero; using robotic systems the precision of the intervention is below one hundred of a millimetre; the risk of unwanted cuts (vessel sectioning, nerve damage, etc.) is minimal; the number of assistants in the operation room is reduced; 3D visual feedback. Second, training with a surgical simulator offers several advantages. It is similar to a wet laboratory, human cost in the form of adverse outcomes for patients is minimized, and residents can practice in a relaxed learning environment at their own pace. Additionally, training on surgical simulators can be incorporated into a curriculum that is available to residents at any time. Furthermore, the development of physical and cognitive surgical simulators offers an approach for learning which is different from the traditional apprenticeship model. Simulators cannot replace experienced surgical preceptors, but they are fast becoming an attractive and acceptable adjunct in surgical curricula. As the technology improves, the simulations will become more realistic, and the experience will become more valuable. Simulation programs will play a greater role in future surgical education. For what concerns improving patient care and providing technology for healthcare professionals, there are many limitations and obstacles to overcome, before robotic surgery systems and medical simulators being able to be integrated into the medical field. Motivated by the above observations, the goal of this research is to develop a new manipulator in order to improve such electromecanical limitation of the current surgery robotic systems and also to build a new surgery simulator to address some obstacles when doing some open surgery performances.

PurposeTo test the face validity of the hip diagnostics module of a virtual reality hip arthroscopy simulator.MethodsA total of 25 orthopaedic surgeons, 7 faculty members and 18 orthopaedic residents, performed diagnostic supine hip arthroscopies of a healthy virtual reality hip joint using a 70° arthroscope. Twelve specific targets were visualised within the central compartment; six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. This task was immediately followed by a questionnaire regarding the realism and training capability of the system. This consisted of seven questions addressing the verisimilitude of the simulator and five questions addressing the training environment of the simulator. Each question consisted of a statement stem and 10-point Likert scale. Following similar work in surgical simulators, a rating of 7 or above was considered an acceptable level of realism.ResultsThe diagnostic hip arthroscopy module was found to have an acceptable level of realism in all domains apart from the tactile feedback received from the soft tissue. 23 out of 25 participants (92%) felt the simulator provided a non-threatening learning environment and 22 participants (88%) stated they enjoyed using the simulator. It was most frequently agreed that the level of trainees who would benefit most from the simulator were registrars and fellows (22 participants; 88%). Additionally, 21 of the participants (84%) agreed that this would be a beneficial training modality for foundation and core trainees, and 20 participants (80%) agreed that his would be beneficial for consultants.ConclusionsThis VR hip arthroscopy simulator was demonstrated to have a sufficient level of realism, thus establishing its face validity. These results suggest this simulator has sufficient realism for use in the acquisition of basic arthroscopic skills and supports its use in orthopaedics surgical training.Level of evidenceI.

The Accreditation Council for Graduate Medical Education (ACGME) and American Board of Orthopaedic Surgery (ABOS) recently mandated major changes to curricular requirements for the PGY-1 (intern) year for categorical orthopaedic surgery residents. Since July 1, 2013, PGY-1 residents are required to have 6 months of orthopaedic surgery rotations, 6 months of nonorthopaedic surgery rotations, and complete a mandatory surgical skills curriculum [1, 2]. The ACGME and ABOS executed these changes in an effort to improve the quality and breadth of education for interns, preparing them for more advanced orthopaedic education. These changes were prompted by shifts in general surgery procedures (from open to laparoscopic), which have reduced the operating room experience of suturing and knot tying for interns, as well as by duty hour requirements that further reduce the operating room experience for interns. Together, these shifts in first-year resident experience have resulted in less surgical training for the orthopaedic surgery intern. The new ABOS requirements, which commence on July 1, 2014, seek to offset those losses [1, 2]. This column describes the changes mandated by the ABOS and ACGME for the orthopaedic intern year, discusses some limitations associated with these changes, and offers program strategies for effective implementation.

Understanding surgical education needs in Zambian residency programs from a Resident's perspective

As plastic and reconstructive surgeons, our intimate knowledge of anatomy enables us to operate with confidence across the human body and allows us to engage with colleagues across multiple surgical disciplines to solve complex problems. This also poses a significant challenge to operating surgeons, as they must be adept with the surgical anatomy of the entire human body to deliver optimal surgical outcomes. Precise knowledge of anatomy is an absolute prerequisite for surgical success. Historically, surgical training was supplemented with embalmed cadaveric dissections, as this foundation proved to be an important adjunct to intraoperative education.1 This was thought to be essential because it provided early exposure to human anatomy in an environment where residents could explore without time constraints and could also ask questions to faculty without worry of morbidity to patient care. Recently, ACGME residency guidelines have been amended through work hour restrictions and strict faculty supervision that limit resident independence in the operating room. This has far-reaching implications, as limited operative independence may lead to decreased resident confidence and a diminished surgical skill set.2 The erosion of resident autonomy has forced our surgical educators to search for practical solutions to augment resident education and, in turn, operative skill set. As we know, the fear of surgery is the fear of anatomy, and this proverb underscores the importance of utilizing surgical simulation and cadaver dissections to achieve these goals. Multiple institutions have implemented a cadaver-based curriculum showing promising results. Srinivasan et al3 and Askari et al4 developed curriculums at their respective institutions with the goal of standardizing exposure to fundamental skills to improve resident autonomy.3,4 They found that their cadaveric curriculum increased resident autonomy, as both residents and faculty had improved confidence in the trainee's operative skills. In addition, faculty observed an increase in knowledge of anatomy and in technical skill ability amongst all resident cohorts. Faculty members surveyed at the conclusion of the course also believed that the residency program should continue cadaver-based studies and simulations.3,4 Additional benefits of surgical simulation or cadaver dissections include the potential to identify poor technical knowledge and poor surgical techniques early in training, which allows for individualized educational plans for struggling residents.3 Conversely, skilled junior residents will obtain the opportunity to refine more complex surgical skills. In conclusion, although cadaveric dissections and surgical simulation models will never be a complete substitute for operative experience, history has shown us the importance of using these resources as an adjunct in residency training (Fig. 1). In today's landscape for surgical education, utilization of these resources could translate to more faculty entrustment, increased resident confidence, and increased autonomy in the operating room. Although this model may be cost-prohibitive, there have been multiple strategies employed to mitigate this issue, such as outreach to program alumni, business and industry sponsorship, or creating collaborative relationships amongst departments.1 Furthermore, we recognize the differences in access to cadaveric models in international training programs and hope to reconcile these disparities to achieve widespread access to cadaveric dissections. While surgical simulation and cadaver studies in the current literature have focused on technical skill acquisition, we need to begin to validate patient outcomes and safety benefits, trainee confidence levels, and degree of achieved autonomy to supplement the literature.Fig. 1.: Landmark anatomical study by Siebert et al5 describing the blood supply to the LeFort 1 maxillary segment. From Siebert JW, Angrigiani C, McCarthy JG, et al. Blood supply of the Le Fort I maxillary segment: an anatomic study. Plast Reconstr Surg. 1997;10(Supp. 1):843–851. © 1997, Wolters Kluwer Health. Used with permission.The Creative Commons license does not apply to this content. Use of the material in any format is prohibited without written permission from the publisher, Wolters Kluwer Health, Inc. Please contact [email protected] for further information.DISCLOSURE The authors have no financial interest to declare in relation to the contents of this article. No funding was received for this work.

To construct patient-specific physical three-dimensional (3D) models of renal units with materials that approximates the properties of renal tissue to allow pre-operative and robotic training surgical simulation, 3D physical kidney models were created (3DSystems, Rock Hill, SC) using computerized tomography to segment structures of interest (parenchyma, vasculature, collection system, and tumor). Images were converted to a 3D surface mesh file for fabrication using a multi-jet 3D printer. A novel construction technique was employed to approximate normal renal tissue texture, printers selectively deposited photopolymer material forming the outer shell of the kidney, and subsequently, an agarose gel solution was injected into the inner cavity recreating the spongier renal parenchyma. We constructed seven models of renal units with suspected malignancies. Partial nephrectomy and renorrhaphy were performed on each of the replicas. Subsequently all patients successfully underwent robotic partial nephrectomy. Average tumor diameter was 4.4cm, warm ischemia time was 25min, RENAL nephrometry score was 7.4, and surgical margins were negative. A comparison was made between the seven cases and the Tulane Urology prospectively maintained robotic partial nephrectomy database. Patients with surgical models had larger tumors, higher nephrometry score, longer warm ischemic time, fewer positive surgical margins, shorter hospitalization, and fewer post-operative complications; however, the only significant finding was lower estimated blood loss (186cc vs 236; p=0.01). In this feasibility study, pre-operative resectable physical 3D models can be constructed and used as patient-specific surgical simulation tools; further study will need to demonstrate if this results in improvement of surgical outcomes and robotic simulation education.

β-Blockade Affects Simulator Scores